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LIBRARY   \sg] 

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uwvensmr 

CAUfORNU 


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THE    SURGICAL    DISEASES 


OF 


CHILDREN 


THE   SURGICAL  DISEASES 


OF 


CHILDREN 


AND   THEIR 


TREATMENT  BY  MODERN  METHODS 


BY 

D'ARCY    POWER 

M.A.,  M.B.  Oxon.,  F.R.C.S    Eng. 

DEMONSTRATOR   OF   OPERATIVE  SURGERY   AT   ST.  BARTHOLOMEW'S   HOSPITAL  ; 

SURGEON   TO    THE  VICTORIA    HOSPITAL    FOR   CHILDREN,    CHELSEA  ; 

EXAMINER    IN   THE   UNIVERSITY   OF    DURHAM  ; 

MEMBER    OF   THE  CONJOINT    EXAMINING    BOARD   OF   THE    ROYAL   COLLEGE   OF 

PHYSICIANS    (LOND.)    AND   OF   SURGEONS    (ENG.) 


WITH  ILLUSTRATIONS 


PHILADELPHIA 

BLAKISTON,    SON    &    CO 

I012     WALNUT     STREET 
1898 


TO 

HOWARD    MARSH,  F.R.C.S.  Eng. 

CONSULTING   SURGEON   TO   THE   CHILDREN'S   HOSPITAL 

IN 

Great  Ormond  Street 
Cbis  motk  is  BeMcatefr 

BY 

a  former  pupil 

The  Author. 


Apuiv   eifaonpreTi'  /j.a\\ov  7]  vucav  kcu'wj. 


PREFACE 

Little  excuse  appears  to  be  needed  for  the  present  work. 
The  surgery  of  childhood  is  singularly  wanting  in  text- 
books. There  are  but  a  few  in  German,  still  fewer  in 
French.  In  English,  only  the  works  of  Mr.  Holmes  and 
Mr.  Owen  are  devoted  to  pure  surgery.  Messrs.  Ashby 
and  Wright's  excellent  treatise,  and  Keating's  Cyclo- 
paedia of  the  Diseases  of  Children,  combine  medicine 
with  surgery. 

Some  excuse  is  perhaps  necessary  for  the  fact  that 
the  work  is  written  by  a  single  individual,  and  not  by 
that  system  of  collaboration  which  is  now  fashionable  in 
medical  literature.  I  believe,  however,  that  the  loss 
in  detail  is  more  than  balanced  by  the  gain  in  harmony, 
for  conflicting  statements  are  less  likely  to  be  made 
when  a  book  is  written  by  one  person. 

I  have  endeavoured  to  state  briefly  and  yet  clearly  the 
various  methods  connected  with  the  treatment  of  the 
surgical  diseases  of   children,  which  have  proved  them- 


Vlll  PREFACE 

selves  the  most  successful  in  my  hands.  The  work  has 
been  made  as  practical  as  possible,  and  only  so  much 
pathology  has  been  introduced  as  is  necessary  to  show 
why  the  modern  treatment  differs  from  that  formerly 
employed.  My  position  as  a  surgeon  to  the  Victoria 
Hospital  for  Children,  has  given  me  ample  opportunity 
of  performing  the  more  common  operations  ;  whilst  as  a 
teacher  of  operative  surgery  and  tutor  in  surgery  at  the 
largest  metropolitan  school  of  medicine,  I  have  been 
obliged  to  acquaint  myself  with  the  most  recent  surgical 
work  both  at  home  and  abroad.  The  necessity  of  keeping 
the  book  within  a  reasonable  compass  has  led  to  an 
apparent  neglect  of  the  orthopaedic  side  of  children's 
surgery.  I  have  the  less  regret  for  this  omission  as  there 
are  already  several  excellent  treatises  upon  this  subject, 
and  Mr.  Walsham  promises  us  a  still  more  complete 
one,  of  which  a  part  is  to  appear  in  the  near  future. 

I  have  not  hesitated  to  make  very  free  use  of  the  papers 
of  Dr.  Macewen,  Mr.  Howse,  Mr.  Clutton,  Mr.  Ballance, 
Dr.  Brothers,  Dr.  Aldibert,  Dr.  Byerson  Fowler,  Dr. 
Felizet  and  others,  for  these  writers  are  past-masters  in 
the  subjects  of  which  they  treat,  and  my  own  limited 
experience  is  as  nothing  when  compared  with  theirs.  The 
collection  of   TMses  for  the  Faris  M.D.,  which  is  being 


PREFACE  IX 

augmented  daily  at  the  Library  of  the  British  Medical 
Association,  has  afforded  me  invaluable  assistance,  for 
each  contains  an  excellent  bibliography  in  addition  to  the 
original  work  which  is  often  important.  I  have  appended 
a  list  of  papers  chiefly  remarkable  for  the  excellence  of  the 
bibliography  which  they  contain,  or  for  their  historical 
interest.  It  does  not  pretend  to  be  more  than  a  guide  to 
those  who  wish  to  pursue  each  subject  more  thoroughly 
than  can  be  done  in  a  text-book,  but  to  make  it  useful  I 
have  been  at  considerable  trouble  to  verify  my  references, 
and  so  to  adopt  a  rule  which  is  more  often  honoured  in 
the  breach  than  in  the  observance. 

It  is  my  pleasant  duty  to  thank  most  cordially  those 
gentlemen  who  have  kindly  assisted  me.  My  father  and 
Mr.  W.  H.  C.  Staveley  have  done  me  good  service  in  read- 
ing the  proofs  ;  Prof.  Reid,  Dr.  Colcott  Fox,  Mr.  B^ant, 
Mr.  Jonathan  Hutchinson,  jun.,  Mr.  Battle  and  Mr.  Lock- 
wood  have  lent  me  blocks,  whilst  the  Staff  of  St.  Bartholo- 
mew's and  of  the  Westminster  Hospitals  have  permitted 
me  to  make  drawings  of  specimens  in  their  museums.  Dr. 
Sims  Woodhead  and  Dr.  Kanthack  have  been  good  enough 
to  revise  what  I  had  written  upon  some  of  the  more 
recent  bacteriological  work  in  connection  with  diphtheria 
and  with  actinomycosis.     Dr.   Lewis  Jones  has  also  laid 


X  PREFACE 

me  under  an  obligation  by  reading  through  the  pages  on 
the  electrolysis  of  nssvi.  I  am  further  indebted  to  Mr. 
Lewis,  Messrs.  Cassell,  Messrs.  Down,  the  publishers  of 
Testut's  Anatomie  and  of  Hoffa's  Lehrbuch,  for  the 
readiness  with  which  they  acceded  to  my  request  for 
clichtis  of  the  various  figures  which  are  borrowed  from 
their  works.  To  each  and  all  of  these  gentlemen  I 
offer  my  heartfelt  thanks.. 

26,  Bloomsbury  Square,  W.C. 
Mai-chy  1895j 


CONTENTS 


PAGE 

CHAPTER  I. 
General  Surgical  Considerations 1 


CHAPTER  II. 
Non-Infective  Gangrene 10 

CHAPTER   III. 
Non-Tuberculous  Infective  Diseases 16 

CHAPTER   IV, 
Surgical  Tuberculosis 51 

CHAPTER  V. 
Tuberculous  Disease  of  Bone         ......      62 

CHAPTER   VI. 
Tuberculous  Diseases  of  Joints  and  Bursas       ...       97 

CHAPTER   VII. 
Tumours  and  Syphilitic  Disease  of  Bone    ....     146 

CHAPTER   VIII. 

Injuries  of  Bones — Fractures  and  Separated  Epiphyses.     158 

xi 


Xll  CONTENTS 

PACiR 

CHAPTER   IX. 

Conditions  leading  to  Alterations  that  require  Surgi- 
cal Interference  in  Bones  and  Muscles — Anterior 
Poliomyelitis  —  Scurvy  —  Rickets  —  Scoliosis,  and 
Torticollis 193 

CHAPTER   X. 
Non-Tuberculous  Forms  of  Arthritis 225 

CHAPTER  XI. 

Acquired  Dislocations  and  Congenital  Displacements  of 

Joints 235 

CHAPTER   XII. 

Surgical   Affections   of   the   Lips,    Mouth,   Tongue,  and 

(Esophagus 253 

CHAPTER   XIII. 

Surgical  Diseases  of  the  Tonsils,  Pharynx,  and  Nose    .     273 

CHAPTER   XIV. 
Deformities  and  Diseases  of  the  Ear  ....     290 

CHAPTER   XV. 

Disease   of    the    Temporal   Bone    and    the    Cerebral    In- 
flammations  ARISING   FROM   IT 303 

CHAPTER   XVI. 

Intracranial  Disease  and  its  Surgical  Treatment  .        .     313 

CHAPTER  XVII. 
Surgical  Diseases  of  the  Air  Passages      ....     332 


CONTENTS  Xlll 

CHAPTER   XVI II. 
Surgical  Affections  of  the  Abdomen  and  its  Contents  .     375 

CHAPTER   XIX. 
Heknia  and  its  Treatment     .        .        .         .         .        .        .     401 

CHAPTER   XX. 
Diseases  and  Malformations  of  the  Rectum      .        .        .     422 

CHAPTER  XXI. 

Diseases  and  Injuries  of  the  Kidney 432 

CHAPTER   XXII. 
Diseases  of  the  Bladder         .......     447 

CHAPTER  XXIII. 
Surgical  Affections  of  the  Urethra  ...  .     458 

CHAPTER  XXIV. 
Surgical  Affections  of  the  Testicle' 475 

CHAPTER   XXV. 
Diseases  of  Bloodvessels  and  N^evi 490 

CHAPTER  XXVI. 
Burns  and  their  Treatment — Skin-Grafting      .         .         .     501 

CHAPTER  XXVII. 
Some  Malfoemations  and  Congenital  Deformities     .        .    507 


LIST    OF   ILLUSTRATIONS 


FI8.  PAGE 

1.  Diagram  of  Horrocks'  method  of  transfusion    .        .        .6 

2.  From  a  photograph  showing  how  free  may  be  the  move- 

ment in  children's  joints  even  after  prolonged  drainage  36 

3.  Femur  showing  an  unusual  form  of  periostitis         .        .  38 

4.  Transverse  sections  through  the  bone  depicted  in  fig.  3  .  39 

5.  Diagram  showing    the  ordinary   arrangement   of    the 

sheaths  of   the   flexor  tendons   in  the  forearm  and 

hand 45 

B.     Diagram   to   show   an   abnormal   arrangement   of   the 

same  tendon  sheaths        .......    46 

7.     Diagram    to  show   another   abnormal   arrangement  of 

the  tendon  sheaths  in  the  forearm  .        .        .        .47 

8'.  Diagram  of  a  child  with  spinal  caries  .  .  .  .78 
9.     Diagram  of  a  child  with  ricketty  curvature  of  the  spine     79 

10.  Diagram  to  show  the  method  of  applying  a  plaster-of- 

Paris  case  for  the  treatment  of  spinal  caries         .        .    83 

11.  Taylor's  brace  for  use  in  cases  of  spinal  caries  .        .     85 

12.  Dunn's  modification  of  Barker's  flushing  scoop  .         .     89 

13.  Diagram  of  a  large  psoas  abscess      .        .        .        .         .91 

14.  Diagram  of  a  double  psoas  abscess     .         .        .        .        .92 
Coloured  plate  showing  the  relationship  of  the  synovial 

membranes  to  the  epiphyses  in  the  shoulder,  elbow, 
hip,  knee,  and  ankle 96 


LIST    OF    ILLUSTRATIONS 


XV 


136 

201 

209 
213 

215 
223 


244 


fig.  PAGE 

15.  The  treatment  of  tuberculosis  of  the  hip  by  extension     .  117 

16.  Thomas'  knee-splint  in  use 128 

17.  Howse's  splint,  with  a  swing  cradle,  for  use  after  excision 

of  the  knee 

18.  Bones  of  the  pelvis  and  lower  extremity,  showing  the 

changes  which  occur  in  infantile  scurvy 

19.  Outside  splint,  with  pelvic  band,  for  use  in  the  slighter 

forms  of  knock-knee         ....... 

20.  Diagram  of  plaster  case  for  leg 

21.  22.     Ricketty  deformity  of  the  tibia  before  and  after  the 

operation  of  osteotomy     ....... 

23.  Lorenz's  head-swing,  for  use  in  cases  of  wryneck 

24,  25.    Diagrams  of  the  anatomical  structures   at  a  meta- 

carpo-phalangeal   articulation,  before  and   after  dis- 
location of  the  joint 

26,  27.     Single  and  double  congenital  displacement  of  the  hip  247 

28.  Nipple,  with  flexible  metal  shield,  for  the  use  of  infants 

with  cleft  palate 258 

29.  Diagrams   showing  Prof.   Rose's   method   of   inserting 

sutures  in  the  operation  for  cleft  palate 

30.  Matthieu's  tonsil  guillotine 

31.  Two  forms  of  Gottstein's  curette 

32.  Dalby's.  artificial  nail  .... 

33.  The  cranio-cerebral  topography  in  the  adult 

34.  The  cranio-cerebral  topography  in  a  child 

35.  Skull  of  a  child,  showing  the  points  at  which  the  lateral 

sinus  may  be  trephined   and   the  lateral   ventricles 
may  be  explored       .        . 

36.  Intubation  instruments       .... 

37.  Diagram  of  the  method  of  intubation 

38.  Method  of  feeding  after  intubation    . 

39.  Trendelenburg's  tampon  tracheotomy  tube 

40.  Rubber  tube  for  draining  the  chest  in  empyema 

41.  Fowler's    modification    of     Trendelenburg's    operating 

table 

42.  Diagram  of  a  case  of  exomphalos 


261 
275 
283 
284 
326 
327 


328 
340 
342 
345 
34!  I 
371 

391 

403 


XVI  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

43-45.  Diagrams  of  the  lower  part  of  the  abdomen  to  show 
the  changes  which  take  place  in  the  position  of  the 
external  abdominal  ring  as  the  child  grows.        .  405-407 

46-49.    Normal   and   abnormal  conditions  of    the  external 

abdominal  ring 408,  409 

50.  Processus   vaginalis  at   the   eighth    month    of    intra- 

uterine life 410 

51.  Macewen's  hernia  needle 420 

52.  Instruments  used  for  litholapaxy 450 

53.  54.     Diagrams   showing  Felizet's   method   of   forming  a 

new  frsenum  during  the  operation  of  circumcision  .  464 
55.     Bladder  and  kidneys,  showing  the  effects  of  an  untreated 

phimosis 467 

50.     Torsion  of  the  spermatic  cord 482 

57,  58.    A  child  with  cystic  lymphangioma,  before  and  after 

operation 498,  499 

59.  Pelvic  cyst,  showing  its  relations  to  the  rectum        .        .  516 

60.  Child   with    congenital    overgrowth    of    the    feet    and 

secondary  hypertz-ophy  of  the  legs  ....  520 


THE    SURGICAL     DISEASES 
OF    CHILDREN 


CHAPTER    I 

GENERAL   SURGICAL   CONSIDERATIONS 

The  surgical  diseases  of  childhood  only  need  a  special 
study  in  young  children;  for  as  the  age  of  the  patient 
increases,  he  comes  more  and  more  under  the  hand  of  the 
general  surgeon.  The  children's  surgeon  requires  some 
special  qualifications  if  he  is  to  be  successful  in  the 
practice  of  his  art.  He  must  he  rather  more  observant 
than  the  surgeon  who  deals  chiefly  with  adults,  for  much 
can  be  learnt  from  an  attentive  study  of  the  little  patient, 
who  is  as  yet  unable  to  express  his  feelings  or  his 
symptoms.  He  must  be  very  gentle  in  all  his  manipula- 
tions, for  the  tissues  are  but  fragile  and  the  sensations 
are  very  acute.  He  must  be  sympathetic,  and  must  possess 
the  power  of  winning  a  child's  affections,  and  that  quickly  ; 
for  when  such  confidence  is  once  obtained,  the  child  will 
permit  many  liberties  to  be  taken  with  it  which  would 
otherwise  be  impossible.  Above  all,  the  children's  surgeon 
must  be  possessed  of  as  keen  an  eye  and  as  unerring  a 
hand  as  a  skilful  operator  for  cataract,  since  most  of  his 
operations  have  to  be  done  in  a  limited  space  and  upon 

15 


2  THE    SURGICAL    DISEASES    OF    CHILDREN 

the  most  delicate  structures.  In  fine,  the  children's  sur- 
geon should  be  the  antithesis  of  the  late  Poet  Laureate's 
ideal,  "  big  voice,  big  chest,  big  merciless  hands." 

There  are  a  few  points  which  render  surgical  practice 
amongst  children  different  from  that  which  obtains 
amongst  adults.  The  difficulties  of  diagnosis  are  usually 
greater,  for  a  young  child  is  unable  to  localise  its  sensa- 
tions or  to  give  expression  to  its  feelings,  and  more  time 
has  therefore  to  be  spent  in  ascertaining  the  nature  of  a 
difficult  case.  A  lack  of  observation  or  a  want  of  care 
often  leads  to  lamentable  results :  a  fracture  may  be  over- 
looked, the  bellyache  of  spinal  caries  may  be  incorrectly 
interpreted,  the  pain  and  fever  of  acute  infective  osteo- 
myelitis may  be  attributed  to  any  but  the  right  cause. 
Children,  on  the  other  hand,  have  less  control  over  their 
feelings,  and  by  their  instinctive  actions  often  give  a  clue 
to  the  nature  of  their  illness.  Too  much  attention  can 
hardly  be  paid  to  the  attitude  of  a  sick  child  ;  his  cry,  his 
gestures,  and  often  his  very  expression  afford  the  most 
valuable  information  to  those  who  can  read  them  aright. 
The  diagnosis  of  an  injury  is  rendered  more  easy  by 
the  readiness  with  which  a  child  can  be  stripped  and 
examined  from  head  to  foot.  Its  difficulty  is  increased,  on 
the  other  hand,  by  the  fact  that  young  children  are  often 
very  fat,  and  that  many  of  the  bony  points  which  are  so 
useful  in  adults  as  landmarks  are  as  yet  undeveloped.  It 
is  almost  superfluous  to  say  that  in  examining  a  child  the 
most  superficial  methods  should  first  be  employed,  and 
then  as  the  child's  confidence  is  gained  those  which  are 
more  terrifying  or  painful.  The  exercise  of  a  little  discre- 
tion will  often  enable  a  careful  surgeon  to  probe  a  wound 
or  to  examine  the  naso-pharynx  without  the  use  of  any 
anaesthetic,  and  with  comparatively  little  discomfort  to  the 
patient  or  to  himself. 


GKNERAL    SURGICAL    CONSIDERATIONS  3 

Rest  and  the  conservation  of  parts  are  two  golden  rules 
in  the  treatment  of  the  surgical  diseases  of  childhood. 
Nowhere  is  the  brilliant  surgeon  more  completely  out  of 
place  than  in  the  operating  theatre  and  wards  of  a 
hospital  for  children.  The  whole  tendency  of  modern  sur- 
gery is  towards  the  performance  of  atypical  rather  than  of 
formal  operations,  for  the  best  results  are  obtained  by  put- 
ting the  tissues  in  a  position  to  cure  themselves.  Yet  rest 
and  the  conservation  of  parts  may  do  harm  if  carried  to 
an  extreme,  as  is  too  often  seen  in  joint  disease,  in  the 
treatment  of  tuberculous  glands,  and  in  insufficiently  bold 
operations  upon  harelip.  When  an  operation  has  been 
decided  upon,  it  will  generally  be  found  that  better  results 
are  obtained  if  the  child  be  removed  from  its  accustomed 
surroundings  and  is  placed  in  the  charge  of  those  who 
have  special  experience  in  nursing  sick  children.  Only  in 
very  exceptional  cases  can  a  mother  be  trusted  to  nurse 
her  own  child  after  a  serious  operation,  and  in  many 
instances  the  recovery  of  a  spoilt  and  fractious  child  is 
seriously  retarded  by  the  presence  of  those  who  love  it 
best.  It  is  therefore  acting  in  the  best  interests  of  the 
child,  to  recommend  that  it  should  be  placed  a  few  days 
before  a  capital  operation  in  a  surgical  home,  or  in  the 
charge  of  an  experienced  children's  nurse.  It  is  also  well 
to  delay  an  operation  of  any  magnitude,  if  it  be  possible, 
until  the  expiration  of  the  incubation  periods  of  the  exan- 
themata from  which  the  child  has  not  yet  suffered,  and 
until  it  has  recovered  from  its  home-sickness. 

Children  as  a  rule  bear  general  anaesthetics  excellently 
for  a  short  time,  but  they  soon  become  collapsed,  so  that 
no  operation  should  be  unduly  prolonged ;  and  I  do  not 
remember  to  have  seen  a  case  in  which  it  appeared  to  be 
inadvisable  to  give  chloroform.  Local  anaesthetics  are 
useless  in  young  children.      When  chloroform  has  to  be 


4  THE    SURGICAL    DISEASES    OF    CHILDREN 

given,  care  should  be  taken,  in  addition  to  the  ordinary 
precautions,  that  the  child  is  not  faint  from  hunger.  It  is 
therefore  a  rule  in  my  practice,  when  the  operation  is  done 
at  nine  or  ten  in  the  morning,  to  order  the  patient  to  take 
a  good-sized  teacupful  of  warm  milk  at  seven  o'clock.  The 
chloroform  should  not  be  given  too  quickly,  for  the  child 
often  cries  and  makes  such  deep  inspirations  as  to  render  it 
difficult  to  regulate  the  amount  of  vapour  passing  into  the 
lungs.  It  is  perfectly  possible,  and  it  is  often  well,  to 
administer  chloroform  to  a  sleeping  child ;  for  many  of  the 
smaller  operations,  such  as  squint  and  others  in  which  no 
dressings  are  required,  may  thus  be  performed  absolutely 
without  the  knowledge  of  the  patient. 

Children  bear  hunger,  cold,  pain  and  loss  of  blood  very 
badly,  so  that  these  are  the  main  points  to  guard  against 
in  operating  upon  them.  It  has  long  been  our  custom  at 
the  Victoria  Hospital  for  Children  to  prevent  loss  of  heat 
in  infants  during  the  performance  of  an  operation  by  plac- 
ing them  upon  a  water  bed  half  filled  with  water  at  100° 
F.,  and  wrapping  up  all  exposed  parts  in  a  thick  layer  of 
absorbent  wool,  kept  in  place  by  light  bandages.  After 
the  removal  of  a  child  to  its  cot,  hot  water  bottles  or  hot 
bricks  will  be  sufficient  to  maintain  its  heat,  the  nurses 
being  warned  against  placing  them  in  such  a  way  as  to 
allow  the  child  to  be  burnt  or  blistered.  Loss  of  blood 
during  operations  upon  the  limbs  is  usually  prevented  by 
the  application  of  an  Esmarch's  bandage  ;  though  there  are 
some  cases,  as  in  excision  of  the  knee  or  elbow,  where  the 
subsequent  oozing  of  blood  prevents  this  method  being  of 
service.  It  is  most  useful  during  the  removal  of  sequestra, 
and  the  cavity  should  be  thoroughly  packed  with  gauze 
before  the  tubing  is  relaxed.  Haemorrhage  is  arrested  in 
other  cases  by  the  use  of  pressure  forceps,  which  may  be 
employed   with   much    greater  freedom    and   certainty  in 


GENERAL    SURGICAL    CONSIDERATIONS  5 

children  than  in  adults,  owing  to  the  greater  contractility 
of  the  arterial  walls.  Care  must  alwa}Ts  be  taken  com- 
pletely to  arrest  bleeding  before  the  wound  is  closed. 
This  is  important,  because  operation  wounds  in  children 
much  more  often  heal  by  first  intention  than  they  do  in 
adults,  and  it  should  be  the  endeavour  of  the  surgeon  to 
obtain  so  gratifying  a  result  in  every  case,  for  when  this 
is  done  the  scars  after  a  few  years  are  as  inconspicuous 
as  those  seen  after  a  successful  operation  for  the  cure  of  a 
harelip. 

Transfusion  in  cases  of  collapse  from  the  loss  of  blood 
is  often  instrumental  in  saving  a  child's  life.  A  saline 
solution  is  generally  used,  for  the  theory  of  its  beneficial 
effect  is  that  it  acts  by  maintaining  the  blood-pressure, 
and  so  enabling  the  heart  to  beat  under  the  least  disad- 
vantageous conditions  until  fresh  blood  can  be  produced, 
and  in  sufficient  quantity  to  make  up  for  that  which  was 
lost.  Landerer  says  that  salt  solutions  are  useless  in 
animals  when  the  loss  of  blood  exceeds  4|  per  cent,  of  the 
body  weight.  He  employs  a  solution  consisting  of  common 
salt  5iss.,  white  sugar  5viss.,  dissolved  in  li  pints  of  dis- 
tilled water,  to  which  one  or  two  drops  of  caustic  soda 
have  been  added.  Kronecker's  formula  is  somewhat 
simpler.  It  is  l.V  pints  of  water,  to  which  110  grains 
of  common  salt  and  1  grain  of  sodium  carbonate  have 
been  added.  The  solution  in  either  case  must  be  hardly 
alkaline,  and  it  must  be  introduced  at  the  temperature 
of  the  body.  A  teaspoonful  of  common  salt  in  a  pint  of 
water  is  sufficiently  near  a  06  per  cent,  saline  solution 
for  ordinary  purposes  when,  as  usually  happens,  the 
operation  of  transfusion  has  to  be  hurriedly  performed. 
The  method  recommended  by  Dr.  Horrocks,  as  seen  in 
fig.  1,  is  simple  and  effective.  One  of  the  veins  at  the 
bend  of  the  elbow  is  exposed,  and  this  is  no  easy  operation 


6  THE    SURGICAL    DISEASES    OF    CHILDREN 

in  a  bloodless  child.  It  may  therefore  be  necessary  to  lay 
bare  one  of  the  vense  comites  of  the  brachial  artery,  and  to 
pass  the  cannla  into  it  instead  of  into  one  of  the  superficial 
veins.  The  solution  is  allowed  to  flow  into  the  proximal 
portion  of  the  vein  through  a  glass  canula  connected  by 


Fig.  1.— Diagram  of  Horrocks'  method  of  transfusion. 

an  india-rubber  tube  with  a  small  glass  funnel  held  three 
or  four  inches  above  the  arm.  The  india-rubber  tube 
should  be  provided  with  a  clip  to  allow  the  air  to  be 
expelled  and  the  tube  to  be  kept  full  of  the  saline  solution. 
The  fluid  is  then  allowed  to  flow  into  the  vein  until  the 
pulse  shows  that  a  marked  improvement  has  taken  place  in 


GENERAL    SURGICAL    CONSIDERATIONS  7 

the  circulation.  There  need  be  no  fear  of  introducing  too 
large  a  quantity,  but  half  a  pint  to  a  pint  is  generally 
sufficient.  The  canula  is  removed,  the  vein  is  ligatured, 
and  the  wound  is  closed  and  dressed  in  the  ordinary 
manner. 

Nearly  all  the  forms  of  lower  life  flourish  luxuriantly 
in  and  upon  children,  so  that  their  convalescence  after 
an  operation  is  often  retarded  or  arrested  by  one  of  the 
exanthemata.  So  prone  are  children  to  support  microbic 
life  that  the  vast  number  of  surgical  diseases  are  clue  to 
one  or  other  of  the  protophytes  which  have  effected  a 
lodgment  in  their  tissues  or  organs.  They  have  the  power 
of  destro}Ting  many  of  these  micro-organisms  if  their 
bodies  be  placed  under  favourable  conditions,  and  even 
the  most  prolonged  suppuration  they  often  bear  well  and 
recover  from.  They  should  never,  however,  be  left  to  fight 
for  themselves  in  such  cases,  for  the  surgeon  should  make 
every  endeavour  to  remove  the  cause  of  the  suppuration 
as  soon  as  possible.  An  effort,  too,  should  always  be  made 
to  abolish  any  pain  from  which  a  child  may  be  suffering, 
for  if  this  can  be  done  he  will  often  play  and  sleep  as  well 
as  when  he  is  in  perfect  health.  Unlike  adults,  children 
look  neither  before  nor  after,  they  live  for  and  in  the  hour, 
and  so  long  as  they  are  free  from  pain  they  are  careless  of 
slight  inconveniences.  Over  and  over  again  I  have  seen 
a  child  upon  whom  an  hour  before  I  had  performed  an 
osteotomy,  or  whose  tendons  I  had  divided,  eating  a  hearty 
meal,  and  talking  and  laughing  as  if  nothing  had  hap- 
pened. 

The  indications  given  by  the  thermometer  are  of  much 
less  clinical  value  than  in  adults.  A  passing  digestive 
disturbance,  pain,  sleeplessness,  and  such  physical  causes 
as  terror  or  a  fit  of  temper,  are  sufficient  to  raise  a  child's 
temperature  in  a  manner  which  is  appalling  to  those  who 


8  THE    SURGTCAL    DISEASES    OF    CHILDREN 

are  not  forewarned  of  its  slight  importance.  Sudden  and 
transient  elevations  of  temperature  are  not  unusual  in 
cases  of  tuberculous  arthritis  in  which  the  inflammation  is 
apparently  local.  We  do  not  know  the  cause  of  these 
sudden  feverish  attacks,  but  they  are  of  bad  import  and 
are  possibly  associated  with  dissemination  of  the  disease, 
though  for  weeks  afterwards  there  may  be  no  evidence  of 
any  generalisation  having  taken  place.  A  transient  rise 
of  temperature  may  be,  and  usually  is,  of  small  diagnostic 
importance ;  but  a  permanent  rise  or  a  hectic  temperature 
has  the  same  value  in  children  as  in  adults,  and  its  cause 
should  be  as  carefully  ascertained  and  treated.  A  tem- 
perature which  is  only  slightly  above  normal  does  not 
necessarily  imply  that  everything  is  going  on  well  after 
an  operation  in  a  child,  for  extensive  suppuration  may  be 
coincident  with  quite  a  low  body  temperature ;  perhaps 
because,  as  the  young  tissues  are  more  elastic,  the  tension 
is  less  marked,  and  there  is  less  septic  absorption. 

The  treatment  after  operations  in  children  is  not  usually 
attended  with  any  difficulty,  for  a  sick  child  almost  in- 
stinctively keeps  a  seriously  injured  part  at  rest.  They 
are  usually  very  amenable  to  moral  persuasion  in  less 
severe  cases,  and  they  are  so  conservative  that  when  once 
they  have  been  taught  to  lie  still  they  will  often  continue 
to  do  so  for  an  indefinite  length  of  time. 

Children  so  frequently  suffer  from  poisonous  symptoms 
after  the  use  of  carbolic  solutions  and  of  iodoform  that  I 
have  ceased  to  use  them  for  some  time  past,  and  I  have 
contented  myself  with  freshly  boiled  water  to  flush  wounds 
and  sinuses.  I  have  also  made  use  of  camphorated  naph- 
thol  for  packing  cavities,  and  a  solution  of  one  and  a  half 
or  two  volumes  per  cent,  in  water  of  hydrogen  peroxide 
for  dressing  suppurating  tracts.  Camphorated  naphthol, 
invented  by  Desesquelle  of    the  Lariboisiere  Hospital  in 


GENERAL    SURGICAL    CONSIDERATIONS  9 

Paris,  is  a  colourless  liquid,  obtained  by  pounding  sepa- 
rately one  part  by  weight  of  /3-naphthol  and  two  parts  by 
weight  of  camphor.  The  two  powders  are  mixed,  warmed 
gently  and  filtered.  Camphorated  naphthol  is  insoluble  in 
water,  but  it  is  readily  soluble  in  oil,  alcohol,  ether  and 
chloroform,  It  must  be  used  with  some  care,  as  poisonous 
symptoms  have  been  produced  by  leaving  an  ounce  and  a 
half  in  a  cavity.  I  have  never  seen  any  ill-effects  follow 
the  use  of  two  to  four  drachms,  but  often  great  benefit. 
It  produces  a  copious  fluid  discharge  and  the  wound  heals 
kindly,  but  the  tendency  for  the  discharge  to  dry  renders 
it  necessary  to  paint  the  margins  of  the  wound  with  oil  to 
prevent  the  sticking  of  the  dressings. 

Dressings  of  cyanide  gauze,  or  of  gauze  which  has  been 
sterilised  by  heat  without  the  addition  of  any  antiseptic, 
are  less  irritating  than  the  ordinary  forms  of  medicated 
dressings,  and  are  therefore  better  suited  to  the  delicate 
skins  of  children.  The  dressings  should  always  be  as  light 
as  possible,  and  they  should  not  be  applied  with  too  tight  or 
too  heavy  a  bandage.  There  is  a  little  tendency  to  fall 
into  these  errors  of  bandaging  owing  to  the  absence  of 
well-defined  bony  points  in  children,  for  the  surgeon  feels 
as  if  the  bandage  were  insecurely  applied.  It  is  often  very 
difficult  in  young  children  to  keep  the  dressings  clean  and 
sweet  when  they  are  applied  to  the  thighs  and  pelvis,  and 
this  forms  a  special  difficulty  in  the  treatment  of  hernia 
by  the  radical  operation  and  in  many  cases  of  fracture  and 
wounds  of  the  thigh.  It  must  be  counteracted  by  the 
judicious  application  of  waterproof  over  the  dressings,  by 
varnishing  the  plaster-of-Paris  splints  with  ordinary  spirit 
or  finishing  varnish,  and  by  much  extra  vigilance  upon 
the  part  of  the  nurse. 


CHAPTER  II 
NON-INFECTIVE   GANGRENE 

etiology. — Non-infective  gangrene  is  occasionally  met 
with  in  children  and,  as  in  the  adult,  its  cause  is  either 
local  or  general.  The  local  causes  are  interference  with 
the  blood  supply  from  pressure  upon  the  vessels  after 
fracture,  the  pressure  being  exerted  by  the  ends  of  the 
bones  themselves  or  by  a  badly  applied  bandage.  It  may 
occur  as  the  result  of  a  severe  crush  or  compound  fracture 
which  has  led  to  rupture  or  obliteration  of  the  vessels  or  to 
injury  of  the  large  nerves.  It  occasionally  follows  too  long 
an  application  of  an  Esmarch's  bandage  to  the  limbs  of 
weakly  children.  Gangrene,  due  to  constitutional  causes, 
occurs  in  Raynaud's  disease,  sometimes  in  the  later 
stages  of  typhoid  fever,  and  in  the  diabetes  of  children 
about  the  age  of  puberty.  It  is  especially  liable  to  occur 
in  the  ill-nourished  and  in  hospital  practice,  where  even 
trivial  wounds  occurring  in  children  from  the  lowest  neigh- 
bourhoods frequently  slough. 

Pathology. — The  pathological  conditions  are  the  same  as 
in  adults.  The  tissues  die  as  a  result  of  interference  with 
the  blood  supply,  and  are  cast  off  by  a  process  of  ulceration 
at  the  expense  of  the  living  tissues  along  a  well-marked 
line  of  demarcation. 

Symptoms. — The   symptoms  are  more  or  less  marked 

pain,  oedema,  alteration  in  the  colour  of  the  skin,  variations 

10 


NON-INFECTIVE    GANGRENE  I  I 

in   the  pulse,    temperature   and    general  condition  of    the 
patient. 

Treatment. — The  treatment  varies  with  the  particular 
form  of  gangrene,  and  is  given  in  detail  in  the  subsequent 
sections. 

Traumatic  Gangrene. 

This  is  rare  in  children,  but  it  is  somewhat  more  frequent 
after  fractures  than  after  other  injuries.  It  is  characterised 
by  the  painless  course  which  it  runs.  It  is  therefore 
advisable  to  see  the  patient  frequently  for  the  first  few 
da}Ts  after  a  splint  has  been  applied,  to  enable  the  surgeon 
to  assure  himself  that  undue  swelling  is  not  leading  to 
this  calamity. 

The  gangrene  which  results  from  the  prolonged  applica- 
tion of  an  Esmarch's  bandage  is  not  often  seen.  It  is 
preceded  by  an  acute  oedema  of  the  part.  The  mortifica- 
tion is  trivial  and,  as  a  rule,  affects  the  edges  of  the  wound. 
It  is,  however,  an  unpleasant  complication,  and  its  possible 
occurrence  should  be  borne  in  mind  when  the  surgeon 
undertakes  prolonged  operations  upon  bloodless  limbs  in 
delicate  children  who  have  a  weak  circulation. 

Raynaud's   Disease. 

etiology. — Spontaneous  gangrene  of  the  extremities, 
which  is  either  symmetrical  or  asymmetrical  and  which 
arises  independently  of  obvious  vascular  obstruction,  occa- 
sionally occurs  in  children,  and  somewhat  more  frequently 
in  girls  than  in  boys.  The  predisposing  and  exciting 
causes  of  the  condition  are  quite  unknown,  but  in  a 
certain  proportion  of  cases  it  seems  to  be  associated  with 
paroxysmal  attacks  of  hemoglobinuria  and  with  peri- 
pheral neuritis.  The  severity  of  the  affection  varies 
greatly ;    in   some  cases  it  is  merely  a  tendency  of   the 


I  2       THE    SURGICAL    DISEASES    OF    CHILDREN 

extremities  of  the  tips  of  the  ears,  of  the  nose,  or  of  cer- 
tain circumscribed  cntaneons  areas,  to  become  numb  and 
bloodless — the  syncopic  form — whenever  the  peripheral 
arterioles  are  contracted,  either  locally  from  the  application 
of  cold  or  reflexly  by  the  dilation  of  the  arterioles  in  other 
parts.  More  severe  lesions  are  present  in  other  instances  ; 
the  extremities  or  other  parts  of  the  body  become  gangren- 
ous, sometimes  superficially,  and  sometimes  the  deeper 
tissues  are  involved  as  in  the  case  (p.  13)  related  below. 
The  symmetry  of  the  gangrenous  patches  is  sometimes 
very  remarkable ;  but  it  is  not  an  essential  condition,  for 
the  gangrene  is  often  unilateral.  The  gangrene  is  either 
of  the  dry  or  of  the  moist  form. 

Symptoms. — The  symptoms  are  often  ill-defined,  and 
the  patients  are  not  seen  until  the  gangrenous  condition  is 
well  established.  The  affected  part  becomes  of  a  lilac 
colour  —  the  asphyxia!  form  —  and  the  patient  complains 
of  tingling,  which  in  a  few  days  may  become  a  severe 
pain.  The  tissues  adjacent  to  the  affected  part  are  often 
a  little  cedematous  and  hypersemic.  The  heart  is  normal, 
and  the  pulse  never  ceases  to  be  perceptible  in  the  arteries 
of  the  affected  limbs,  though  it  may  be  increased  in 
frequency  and  diminished  in  strength. 

Progress. — The  gangrene  generally  follows  a  continuous 
course,  either  acute  or  chronic,  but  the  symptoms  may  be 
intermittent.  Dr.  Raynaud  states  in  his  original  thesis 
that  its  duration  is  never  less  than  twenty  days,  and  never 
more  than  ten  months  ;  but  these  two  terms  are  excep- 
tional, and  the  ordinary  duration  is  three  or  four  months. 

The  Diagnosis  is  not  difficult.  The  incipient  gangrene 
must  be  distinguished  from  chilblains  and  frostbite,  whilst 
the  pain  must  not  be  mistaken  for  that  due  to  rheumatism 
or  neuralgia.  It  must  also  be  distinguished  from  gangrene 
due  to  other  causes. 


NON-INFECTIVE    GANGRENE  I  3 

The  Prognosis  is  not  wholly  good,  for  although  many 
children  affected  with  symmetrical  gangrene  recover,  a 
certain  proportion  die. 

The  Treatment  in  the  earliest  and  simplest  forms  con- 
sists in  stimulating  the  local  circulation  either  by  sham- 
pooing or  by  the  use  of  the  constant  current.  Dr.  Barlow  1 
states  that  he  has  obtained  good  results  by  plunging  the 
extremity  of  the  limb  which  is  the  subject  of  local  asphyxia 
into  a  large  basin  containing  salt  and  water  :  "  Place  one 
pole  of  a  constant  current  battery  on  the  upper  part  of  the 
limb,  and  the  other  in  the  basin,  thus  converting  the  salt 
and  water  into  an  electrode.  Employ  as  many  elements 
ns  the  patient  can  comfortably  bear;  make  and  break  at 
frequent  intervals  so  as  to  get  repeated  but  moderate  con- 
tractions of  the  limbs.  In  a  typical  paroxysmal  case,  if 
two  limbs  be  similarly  affected,  it  will  be  found  that  the 
limb  which  is  subjected  to  the  above  treatment  will  more 
rapidly  recover  than  the  one  which  is  simply  kept  warm." 
This  method  of  treatment  should  be  adopted  both  in  the 
acute  and  in  the  chronic  cases.  During  the  painful  periods 
an  icebag  may  be  applied  to  the  part,  or  if  this  fails  to 
give  relief,  warm  applications  may  be  tried.  Amputation 
is  required  for  aesthetic  purposes  when  the  gangrene  has 
affected  the  deeper  tissues  of  the  fingers  and  toes  ;  but  it 
should  not  be  adopted  until  there  is  a  well-defined  line  of 
demarcation. 

The  following  case  which  recently  came  under  my  care 
will  serve  to  illustrate  the  general  characters  of  the  affec- 
tion. A  girl,  aged  56  months,  but  looking  much  younger, 
was  brought  to  me  in  March,  1893,  suffering  from  gangrene 
of  both  feet.  She  had  been  much  troubled  in  the  winter  of 
1890  with  chilblains,  and  in  November,  1892,  her  feet  and 
legs  became  livid  in  the  evening,  but  were  of  the  natural 
colour    during    the   day.      The   toes    became   black    and 


14       THE    SURGICAL    DISEASES    OF    CHILDREN 

shrivelled  in  December,  1892.  The  fingers  had  always 
been  natural.  The  child  had  never  walked  or  crawled,  but 
there  was  no  paralysis,  and  the  want  of  power  appeared  to 
depend  upon  simple  weakness.  The  father  was  subject  to 
chilblains,  but  there  was  no  family  history  of  phthisis, 
diabetes,  or  heart  disease.  She  occasionally  passed  large 
quantities  of  urine.  The  pulse,  when  I  first  saw  the 
patient,  was  144,  regular  and  of  high  tension.  The  radial 
arteries  were  thickened,  they  were  tortuous,  and  were  more 
easily  felt  than  usual.  Pulsation  could  be  detected  in  the 
dorsalis  pedis  artery  of  each  foot,  and  in  both  posterior 
tibial  arteries.  The  skin  of  the  body  was  natural,  the 
finger-nails  were  cracked  and  the  finger-tips  beneath  the 
nails  were  blue.  The  heart  and  lungs  were  normal.  The 
eyes  were  natural,  and  there  was  no  retinal  haemorrhage. 
All  the  toes  on  both  feet  were  shrivelled  and  black,  and 
the  gangrene  extended  to  the  metatarso-phalangeal  joints. 
There  was  a  small  patch  of  black  skin  about  half  an  inch  in 
diameter  on  the  inner  side  of  the  left  heel,  and  at  a  corre- 
sponding point  upon  the  right  heel  the  skin  appeared  to  be 
redder  than  natural.  The  patient  was  ordered  a  generous 
diet,  with  half  an  ounce  of  brandy  every  twenty-four  hours. 
One-minim  doses  of  tincture  of  opium  with  aromatic  spirits 
of  ammonia  were  given  every  three  hours.  A  line  of  de- 
marcation began  to  be  formed  five  days  after  I  first  saw  her, 
and  nearly  three  months  after  the  beginning  of  the  mortifi- 
cation. The  line  of  demarcation  was  formed  along  each 
series  of  metatarso-phalangeal  joints,  and  at  the  same  time 
the  slough  on  the  left  heel  separated,  leaving  a  small  super- 
ficial ulcer,  whilst  the  red  patch  on  the  right  heel  com- 
pletely disappeared.  Four  days  later,  on  March  18th,  the 
phalanges  of  the  little  toe  on  the  left  foot  were  completely 
separated.  Chloroform  was  administered  on  April  6th, 
and  the  remaining  phalanges  on  both  feet  were  removed. 


NON-INFECTIVE    GANGRENE  I  5 

The  patient  made  an  uninterruptedly  good  recovery,  except 
that  on  April  16th  a  small  black  spot  was  noticed  about 
the  junction  of  the  upper  with  the  middle  third  of  the 
anterior  surface  of  the  right  tibia.  The  child  was  again 
ordered  to  take  one-minim  doses  of  laudanum,  and  the  spot 
disappeared  in  a  few  days.  The  urine  was  repeatedly 
tested  whilst  she  was  under  treatment.  It  was  generally 
neutral  or  feebly  alkaline,  and  it  was  at  all  times  free  from 
sugar,  blood  and  hsemoglobin.  It  contained  crystals  of 
triple  phosphate,  and  on  one  occasion  there  was  a  trace  of 
albumin.  A  year  later,  the  child  was  fat  and  well.  She 
had  passed  through  the  winter  without  any  return  of  her 
old  symptoms. 

Typhoidal  Gangrene. 

My  friend  and  colleague,  Dr.  Dawtrey  Drewitt,2  *  has 
recently  published  a  short  but  complete  account  of 
gangrene  of  the  limbs  following  typhoid  fever.  He  thinks 
that  gangrene  in  this  disease  is  more  frequent  in  children 
than  in  adults,  because  the  young  heart  is  able  to  hold 
out  to  the  end  in  cases  of  typhoid,  where  older  hearts 
would  fail,  and  though  grey  and  bloodless  are  still  able 
to  contract  on  the  half  dried  up  and  clotting  blood- 
stream. The  facts,  that  in  typhoid  fever  the  gangrene 
occurs  late  in  the  disease,  and  is  generally  preceded  by 
a  sudden  pain  in  the  limb,  whilst  the  artery  becomes  big 
with  thrombus,  points,  Dr.  Drewitt  considers,  to  an 
embolic  origin.  He  therefore  recommends  that  cardiac 
stimulants  as  well  as  an  abundance  of  fluid  food  should 
be  given  in  the  later  stages  of  typhoid  fever  to  counter- 
act any  tendency  to  the  formation  of  emboli. 

*  The  Nos.  throughout  refer  to  the  Bibliographical  Appendix. 


CHAPTER   III 
NON-TUBERCULOUS   INFECTIVE   DISEASES 

SAPBJEMIA. 

The  simplest  form  of  septic  disease  is  that  which  arises 
from  a  suppurating  wound.  The  child  is  constipated, 
his  temperature  rises  two  or  three  degrees,  he  is  flushed, 
drowsy,  and  has  a  bad  appetite.  The  neighbouring  lym- 
phatic glands  become  tender,  enlarged,  and  may  suppurate. 
Free  vent  is  to  be  given  to  the  pus  if  it  has  been  confined. 
The  wound  should  be  well  cleansed  and  dressed  antisepti- 
cally,  the  bowels  are  to  be  relieved,  and  in  a  clay  or  two 
all  signs  of  the  fever  will  have  disappeared. 

SEPTICAEMIA. 

More  serious  manifestations  sometimes  present  them- 
selves after  an  operation.  Symptoms  of  a  typhoidal 
character  arise,  and  the  child  passes  through  an  attack 
of  true  septicsemia,  often  associated  with  a  rash.  This 
rash  is  an  erythema  of  infective  origin,  and  is  often  seen 
around  the  seat  of  puncture  after  the  inoculation  of  the 
various  antitoxins.  It  is  not  uncommon  during  conva- 
lescence from  diphtheria  and  typhoid  fever.  It  appears 
first  near  the  joints  or  upon  the  buttocks,  somewhat  less 
frequently  upon  the  belly,  and  still  more  rarely  on  the 
neck.  The  rash  varies  considerably  in  extent,  it  is  fugi- 
tive, and  has  a  great  tendency  to  become  petechial.  It 
is  often  symmetrical,  but  it  does  not  spread.  Its  appear- 
ance is  attended  by  constitutional  symptoms  of  greater  or 
less  severity.    The  temperature  rises,  falls,  and  rises  again, 

the  pulse-rate  is  increased,   the  patient  vomits,  and  has 

it; 


NOX-TUliERCULOUS    INFECTIVE    DISEASES         1 7 

diarrhoea.  The  urine  is  scant}-,  and  may  contain  albu- 
min. These  symptoms  are  truly  septicaemic.  There  is  no 
doubt  that  they  are  caused  by  an  inflammation  which  is 
secondary  to  the  disease  from  which  the  child  is  convales- 
cent, and  that  they  are  due  to  septic  organisms  lurking  in 
the  various  mucous  membranes  of  the  body.  The  attack 
may  be  complicated  by  pneumonia,  bronchitis,  or  pericar- 
ditis. It  does  not  usually  cause  death  in  an  uncomplicated 
form. 

The  Treatment  consists  in  removing  the  local  cause  of 
infection  as  soon  as  possible,  clearing  out  the  contents  of 
the  bowels  with  Rochelle  salts  or  a  calomel  purge,  and,  if 
necessary,  rendering  the  alimentary  tract  aseptic  by  the  ad- 
ministration of  small  doses  of  /3-naphthol.  Quinine  should 
be  given,  with  brandy  and  plenty  of  milk.  The  prophylactic 
treatment  is  to  render  the  mouth  and  pharynx  aseptic 
during  convalescence  from  pneumonia,  diphtheria,  typhoid 
fever  and  other  diseases  which  are  likely  to  lead  to  the 
harbouring  of  micrococci.  This  can  be  done  by  the  use  of 
gargles,  sprays  and  tooth  brushes. 

PYAEMIA. 

etiology.  —  Pyaemia  is  one  of  the  worst  forms  of 
septic  disease,  but  like  septicaemia  it  is  not  very  common 
in  children.  It  is  met  with  in  new-born  infants,  associ- 
ated with  a  similar  puerperal  condition  in  the  mother, 
or  the  child  may  become  affected  independently  from  its 
filthy  surroundings.  Pyaemia  in  older  children  is  perhaps 
most  often  associated  with  neglected  osteomyelitis,  with 
mastoid  abscess,  causing  purulent  infection  of  the  lateral 
sinus,  or  as  a  sequel  of  diphtheria  and  erysipelas.  I  have 
seen  it  follow  excision  of  joints  and  compound  comminuted 
fractures,  when  children  have  been  run  over  by  tramcars. 

Symptoms. — The  pysemic  symptoms  are  the  same   as 

c 


1 8       THE    SURGICAL    DISEASES    OF    CHILDREN 

those  met  with  in  acUilts.  Extreme  prostration,  irregular 
temperature,  repeated  rigors,  sweating,  and  greatly  en- 
feebled cardiac  action  are  the  chief  points.  The  abscesses 
found  in  the  joints  are  not  necessarily  accompanied  by 
increased  febrile  disturbance  at  the  time  they  are  formed, 
though  a  fresh  abscess  is  often  found  within  a  few  hours 
of  a  rigor. 

Course. — Pyaemia  in  children  runs  a  rapid  and  fatal 
course,  characterised  by  the  formation  of  abscesses  in  dif- 
ferent parts,  and  frequently  by  gangrene  of  the  skin.  It 
is  chronic  in  a  few  cases,  and  may  then  cause  secondary 
dislocations  of  one  or  many  joints,  as  a  result  of  the  sup- 
purative arthritis  which  characterises  the  disease. 

Treatment. — The  only  treatment  consists  in  the  free 
administration  of  quinine  and  stimulants,  the  early  opening 
of  secondary  abscesses,  and  the  thorough  cleansing  of  any 
wound.  Ligature  of  the  vein  carrying  blood  away  from 
the  affected  part  is  sometimes  of  service ;  but  this  treat- 
ment is  considered  in  greater  detail  under  the  heading  of 
infective  thrombosis  of  the  lateral  sinus. 

ERYSIPELAS. 

etiology. — Erysipelas  occurs  even  in  new-born  chil- 
dren, for  in  Lebedeff  s  case  the  streptococcus  erysipelatosus 
was  found  in  the  skin  of  a  child  who  died  ten  minutes 
after  its  birth  from  a  mother  who  was  herself  suffering 
from  erysipelas.  It  most  commonly  attacks  the  navel 
and  genital  organs,  though  it  may  also  start  from  abra- 
sions, ulcers  and  eczematous  conditions  of  skin  in  other 
parts.  It  is  not  very  uncommon  after  vaccination,  or 
after  chickenpox.  Young  children  are  especially  liable 
to  attack,  and  they  bear  erysipelas  badly,  for  they  often 
die  rapidly  with  diarrhoea  and  bronchitis,  or  if  they 
recover  from  the  immediate  effects  they  succumb  to  the 


NON-TUBERCULOUS    INFECTIVE    DISEASES        1 9 

inflammatory  and  gangrenous  conditions  of  the  skin  which 
form  such  common  sequelae.  Indeed,  it  is  said  that 
children  under  one  year  old  who  are  attacked  by  erysipelas, 
die,  and  }ret  they  only  suffer  from  the  cutaneous  form. 
Erysipelas  is  very  rare  in  older  children,  and  they  usually 
bear  it  much  better. 

The  Symptoms  are  the  same  as  in  adults.  There  is  a 
well-marked  initial  rigor,  with  vomiting,  delirium,  increase 
of  temperature  to  104-105°  F.,  and  erratic  erythema  with 
the  formation  of  bullse. 

Treatment. — The  treatment  consists  in  the  administra- 
tion of  half -drachm  doses  of  Epsom  salts,  and  as  soon  as  the 
bowels  have  been  well  opened,  a  mixture  containing  tinct. 
ferri  perchlor.  m]  xx.  and  glycerine  5  i-  in  each  ounce  of 
water  should  be  given  three  times  a  day  for  a  child  of 
six  to  eight  years.  Alcohol,  best  given  in  the  form  of 
brandy  or  whisky,  is  nearly  always  required  as  a  stimu- 
lant. The  inflamed  part  should  be  dressed  with  lead  lotion, 
or  it  may  be  powdered  with  oxide  of  zinc. 

CELLULITIS. 

etiology. — Acute  cellulitis  is  rare  in  children,  but  the 
more  chronic  forms  associated  with  infective  disease  are 
by  no  means  uncommon.  They  are  usually  associated 
with  diphtheria,  for  the  relief  of  which  tracheotomy  has 
been  performed,  leading  to  cellulitis  of  the  neck  and  septic 
osteomyelitis,  causing  cellulitis  of  the  limbs  ;  but  cellulitis 
may  also  occur  in  the  course  of  an  attack  of  chickenpox, 
scarlet  fever,  or  measles. 

Symptoms.  —  Primary  cellulitis  is  an  acute  inflam- 
mation, and  runs  a  very  virulent  course.  It  attacks  the 
submaxillary  or,  more  rarely,  the  ischio-rectal  region  in 
children  who  have  been  weakened  by  some  debilitating 
disease,  or  who  from  some  other  cause  are  in  a  bad  state  of 


20       THE    SURGICAL    DISEASES    OF    CHILDREN 

health.  In  the  submaxillary  form  the  lymphatic  glands 
at  the  angle  of  the  jaw  become  enlarged,  but  they  do  not 
suppurate,  and  a  brawny  oedema  very  soon  affects  the  neck, 
from  the  chin  to  the  sternum,  either  ou  one  or  both  sides. 
The  mouth  and  pharynx  often  remain  unaffected,  but  the 
tongue  may  become  swollen,  owing,  Mr.  R.  W.  Parker3 
thinks,  to  the  pressure  of  inflammatory  products  upon  the 
lingual  vein.  The  disease  reaches  its  height  in  two  or 
three  days,  and  is  characterised  by  the  usual  symptoms  of 
septic  infection,  rendered  more  acute  by  the  fact  that  the 
inflammatory  products  are  pent  up  under  a  very  dense 
fascia.  There  is  a  difficulty  in  swallowing  in  some  cases, 
but  in  many  dysphagia  is  by  no  means  a  prominent 
sign.  An  abscess  forms  when  no  treatment  is  employed, 
and  it  opens  either  by  the  side  of  the  tongue,  or  ex- 
ternally at  the  margin  of  the  jaw.  The  patients  recover 
in  a  few  cases,  but  in  too  many  instances  they  die  of 
septicaemia,  and  in  a  very  short  time.  A  similar  condi- 
tion occurs  in  adults,  and  was  first  clearly  described  by 
Dr.  Ludwig,  of  Stuttgart  (Mcdicinisches  Correspondenz- 
blatt,  Bd.  6,  1836,  p.  21),  after  whom  it  has  received  its 
modern  name  of  Angina  Ludovici.:^  It  was,  however, 
known  to  Aretseus  and  to  Paulus  iEgineta,  for  both 
writers  describe  it. 

The  Treatment  consists  in  early  and  free  incisions 
carried  through  the  deep  fascia,  and  with  as  little  loss 
of  blood  as  possible.  The  incisions  should  be  made 
before  gangrene  of  the  cellular  tissue  has  occurred,  and 
when  only  blood-stained  serum  exudes.  Some  effective 
means  of  drainage  must  be  adopted,  and  wounds  must  be 
dressed  antiseptically.  It  is  then  probable  that  the  disease 
will  run  a  simple  suppurative  course.  Quinine,  brandy, 
and  a  sufficient  supply  of  easily  digested  food  are  impera- 
tively demanded. 


NON-TUBERCULOUS    INFECTIVE    DISEASES        2  1 

FURUNCULOSIS. 

This  is  a  very  common  disease  in  the  badly  nourished 
children  of  large  towns.  The  boils  appear  in  crops  upon 
the  trunk  more  often  than  upon  the  extremities,  and  they 
are  often  so  close  together  as  to  lead  to  a  diffuse  suppura- 
tion. They  may  be  so  numerous  and  are  accompanied  by 
so  much  constitutional  disturbance  as  to  put  the  life  of  the 
patient  in  jeopardy. 

The  Treatment  consists  in  feeding  the  child  well  and 
regularly,  and  administering  J-grain  doses  of  calcium  iodide 
or  sulphide  three  times  a  day.  Yeast,  too,  in  doses  of  one  or 
two  teaspoonfuls  three  times  a  day,  may  also  ba  used  with 
advantage  in  some  cases.  It  is  given  quite  empirically, 
for  we  have  no  idea  of  the  manner  in  which  it  acts. 
Poultices  should  not  be  applied  to  the  abscesses,  but  the 
skin  over  them  should  be  carefully  and  gently  washed  with 
soap  and  water ;  and  it  should  then  be  incised,  and  dressed 
with  gauze  soaked  in  a  40  per  cent,  solution  of  carbolic 
acid  or  a  1  in  2000  solution  of  perchloride  mercury. 

PHAGEDENA  AND   SEPTIC   GANGRENE. 

Dr.  Gee  explains  phagedena  to  be  a  rapid  ulceration,  the 
tissues  being  destroyed  particle  by  particle,  and  being  cast 
off  in  like  manner.  In  gangrene  the  dead  tissues  remain 
in  situ  until  the  patient  dies,  or  are  cast  off  in  masses 
called  sloughs.  This  distinction  is  a  real  one,  and  is 
of  practical  value.  Both  phagedsena  and  gangrene  occur 
amongst  children,  and  their  cause  is  either  local  or  consti- 
tutional. The  best  known  form  of  phagedsena  is  noma, 
including  cancrum  oris,  though  it  occasionally  assumes  a 
gangrenous  form. 

Noma  and  cancrum  oris  occur  in  children,  between  the 
ages  of  three  and  six  years,  who  have  been  weakened  by  an 
attack  of  scarlet  fever,  measles,  typhoid,  or  less  frequently, 


2  2        THE    SURGICAL    DISEASES    OF    CHILDREN 

in  the  very  debilitated  without  any  such  predisposing  cause. 
As  the  terms  are  used  in  this  country,  noma  is  usually 
restricted  to  an  acute  inflammatory  condition,  rapidly 
passing  into  phagedena,  and  affecting  the  vulva  or  penis, 
and  more  rarely  the  anus,  whilst  cancrum  oris  is  a  similar 
condition  affecting  the  mouth.  There  is  no  reason,  how- 
ever, why  noma  should  not  be  used  to  the  exclusion  of 
cancrum  oris. 

Course.— The  affection  begins  insidiously  on  the  mucous 
surface  of  the  part  attacked,  the  skin  remaining  white. 
The  deeper  tissues  soon  become  infiltrated,  and  a  small, 
hard  and  round  spot  can  be  detected.  Examination  of  the 
mucous  membrane  will  reveal  a  painless  patch,  covered 
with  a  yellow  secretion.  This  patch  rapidly  spreads,  and 
the  whole  of  the  infiltrated  tissues  are  destroyed.  The 
disease,  as  we  see  it  in  London,  runs  an  acute— gangren- 
ous — and  a  less  acute — phagedsenic — course,  the  slower 
form  being  the  more  usual.  I  have  only  seen  it  amongst 
the  poorest  and  most  neglected  children. 

Treatment.— The  course  of  the  disease  must  be  arrested, 
if  possible,  or  death  will  take  place  in  eight  to  twenty-one 
days  from  pneumonia,  bleeding,  or  starvation.  The  readiest 
means  of  stopping  the  inflammatory  process  is  to  put  the 
patient  under  chloroform,  scrape  away  the  foul  and  softened 
area,  and  then  thoroughly  swab  it  over  with  fuming  nitric 
acid,  or  acid  nitrate  of  mercury,  taking  care  that  none  of 
the  caustic  passes  beyond  the  diseased  tissue,  and  that  all 
excess  is  wiped  away.  Very  great  deformity  sometimes 
results  from  the  destruction  of  the  tissues  if  the  patient 
recovers,  but  in  the  acute  cases  all  remedies  are  too  often 
useless.  Fresh  air,  good  food,  alcohol,  small  doses  of 
opium,  and  local  applications  of  chlorate  of  potash,  will 
assist  the  patient's  convalescence  as  soon  as  the  sloughing 
process  is   arrested.     The   affection   is   no   doubt   due   to 


NON-TUBERCULOUS    INFECTIVE    DISEASES        23 

micro-organisms,   but  no  specific   form  has  yet  been  iso- 
lated. 

GANGRENE  OF  THE  FAUCES  AND  SOFT  PALATE. 

This  may  be  erysipelatous,  but  it  is  sometimes  idio- 
pathic, and  it  then  occurs  as  an  insidious  and  very  fatal 
form  of  disease  in  young  adults. 

Symptoms. — It  commences  as  an  acute  inflammation  of 
the  tonsils,  with  the  ordinary  symptoms  of  pain,  fever, 
dysphagia,  and  constipation.  The  inflammation  rapidly 
passes  on  to  gangrene,  involving  the  soft  palate  and  the 
fauces,  leading  to  the  formation  of  an  extensive  slough. 
The  symptoms  are  not  unduly  severe,  and  there  is  but 
little  pain,  so  that  the  surgeon  is  apt  to  be  thrown  off  his 
guard,  until  the  stinking  discharge  and  a  sharp  haemor- 
rhage from  the  mouth  or  nose  warn  him  of  the  true  nature 
of  the  case. 

Treatment. — The  few  cases  I  have  seen  have  run  a 
rapid  and  fatal  course,  in  spite  of  all  that  could  be  done 
for  them.  The  condition  must  be  distinguished  from 
an  allied  form  of  phagedgenic  ulceration  of  the  fauces, 
which  is  not  uncommon  after  the  exanthemata,  and 
notably  after  scarlet  fever,  diphtheria,  and  typhoid.  This 
secondary  form  is  less  likely  to  kill,  for  it  is  amenable 
to  treatment  internally  by  quinine  and  tonics,  locally  by 
chlorate  of  potash  spray.  The  anterior  pillars  of  the 
fauces  are  found  after  recovery  to  be  perforated,  the  per- 
forations sometimes  being  single  and  sometimes  double. 


*e> 


GANGRENOUS  EMPHYSEMA. 

Pathology. — Malignant  oedema  is  a  very  severe  form 
of  gangrenous  inflammation  produced  by  the  inoculation  of 
a  bacillus  capable  of  spontaneous  movement.  It  is  smaller 
than  the  anthrax  bacillus  and,  during  sporulation,  it  en- 


24        THE    SURGICAL    DISEASES    OF    CHILDREN 

larges  at  one  end  and  forms  an  oval,  brilliant  and  blnish 
spore.  It  is  essentially  an  anaerobic  organism,  and  it 
lives  in  the  earth,  only  occasionally  migrating  to  animal 
tissues. 

etiology. — The  disease  is  due  to  the  direct  inoculation 
of  the  bacillus  into  the  cellular  tissue  of  the  body. 

Symptoms. — The  incubation  period  is  from  a  few  hours 
to  six  days  after  a  more  or  less  severe  injury,  marked  by 
malaise,  and  often  associated  with  pain  around  the  wound, 
and  sometimes  with  so  much  bronzing  of  the  skin  as  to 
lead  Velpeau  to  give  it  the  name  of  erysipele  bronze.  Dr. 
Roswell  Park,  in  his  recent  Mutter  Lectures,  says  that 
the  invasion  period  is  characterised  by  a  rapid  elevation  of 
temperature  which  continues  with  but  trifling  remissions 
until  death.  The  tongue  becomes  dry  and  covered  with  a 
thick  and  foul  fur.  The  patient  soon  loses  consciousness 
or  becomes  apathetic,  complaining  only  of  pain  and  burning 
thirst.  Incontinence  of  urine  and  fasces,  frequent  and 
superficial  breathing,  and  dilatation  of  the  pupil  are  the 
precursors  of  death,  which  may  occur  from  fifteen  to  thirty 
hours  after  the  onset  of  the  acute  symptoms. 

The  inflammation  spreads  rapidly  from  the  wound,  and 
leads  to  a  speedy  destruction  of  the  tissues  with  the  forma- 
tion of  gas.  A  dirty,  reddish-brown  skin,  mottled  with 
blue,  whose  veins  are  filled  with  stagnant  blood,  covers 
the  affected  areas.  The  underlying  tissues  are  sodden  with 
fluid,  and  distended  with  the  gaseous  products  of  decom- 
position. They  yield  a  fine  crepitus,  due  to  subcutaneous 
emphysema.  A  thin  and  foul-smelling  secretion  flows  from 
the  wound. 

Diagnosis. — Gangrenous  emphysema  is  not  always 
malignant  oedema.  It  might  be  mistaken  for  quarter-evil, 
and  a  closely  similar  condition  has  been  met  with  after 
typhoid  fever. 


NON-TUBERCULOUS    INFECTIVE    DISEASES        25 

Prognosis. — The  prognosis  is  serious,  but  not  neces- 
sarily fatal. 

Treatment. — The  treatment  consists  in  making  free  in- 
cisions, with  as  little  loss  of  blood  as  possible,  and  the  most 
thorough  disinfection  of  the  wounds.  The  strength  of  the 
patient  must  be  supported  by  every  possible  means. 

.  ACUTE  RETROPHARYNGEAL  ABSCESS. 

etiology. — Retro-pharyngeal  abscess,4  due  to  inflam- 
mation of  the  deeply  seated  lymphatic  glands  in  the  neck, 
which  receive  the  lymphatics  of  the  tonsil,  soft  palate 
and  pharynx,  is  not  very  infrequent  in  children.  It 
often  occurs  insidiously  and  from  no  very  apparent  cause, 
though  a  cross-examination  of  the  parents  may  elicit  a  his- 
b  try  of  otitis,  nasal  catarrh,  teething,  or  other  chronic  inflam- 
mation of  the  tissues  near  the  pharynx.  The  abscess  is 
associated  with  the  presence  of  several  forms  of  strepto- 
coccus usually  found  in  the  larynx.  It  is  due  in  other  cases 
to  the  burrowing  of  an  abscess  in  the  neck  from  inflammation 
of  the  middle  ear,  or  more  rarely  to  scarlet  fever,  measles, 
or  direct  injury.  A  more  chronic  and  otherwise  widely 
different  form  is  secondary  to  tuberculous  or  other  disease 
of  the  cervical  vertebrse  (p.  81),  when  the  pus  accumulates 
beneath  the  deep  fascia  and  the  anterior  common  ligament ; 
whereas  in  the  acute  cases  it  is  situated  in  the  cellular 
tissue,  between  the  pharynx  and  the  fascia  covering  the 
prevertebral  muscles. 

Symptoms. — The  onset  of  the  disease  is  singularly  in- 
sidious ;  the  child  is  obviously  ill,  but  there  is  nothing  to 
account  for  it  until,  as  the  pharyngeal  swelling  increases, 
deglutition  and  respiration  become  impaired.  Tho  voice  is 
said  to  be  low  and  quacking  like  a  duck  ;  but.  this  was  not 
noticeable  in  any  of  my  cases.     The  child  usually  keeps 


26        THE    SURGICAL    DISEASES    OF    CHILDREN 

its  head  in  a  fixed  position,  either  bent  towards  the  un- 
affected side  when  the  abscess  is  unilateral,  or  inclined 
forwards  when  the  swelling  is  median  or  bilateral. 

Diagnosis. — The  diagnosis  is  readily  made  by  an  exam- 
ination of  the  inside  of  the  mouth,  when  a  swelling  usually 
placed  to  one  side  of  the  middle  line  will  be  seen  bulging 
the  pharynx  forwards.  The  swelling  feels  soft,  fluctuation 
can  be  obtained,  and  its  upward  and  downward  limits  are 
easily  felt,  though  in  some  cases  it  may  pouch  downwards 
like  a  psoas  abscess  (fig.  14),  one  pouch  being  connected 
with  another  by  a  narrow  channel.  When  the  collection 
of  pus  is  considerable  it  may  point  in  the  neck,  pushing 
the  large  vessels  in  front  of  it,  and  giving  rise  to  a  pulsat- 
ing tumour  which  might  conceivably  be  mistaken  for  an 
aneurism.  The  urgent  dyspnoea  often  accompanying  these 
abscesses  makes  it  necessary  to  distinguish  them  from 
croup,  bronchitis  and  oedema  of  the  glottis.  Simple  exami- 
nation of  the  throat  will  establish  the  presence  of  an 
abscess,  whilst  even  slight  external  pressure  upon  the 
larynx  markedly  increases  the  dyspnoea  and  the  pain.  The 
voice  is  less  affected  than  in  croup  or  diphtheria. 

Course. — The  duration  of  the  disease  is  from  two  to  four 
weeks,  though  it  sometimes  runs  an  acute  course  and  opens 
spontaneously,  or  it  may  become  chronic,  as  in  cases  of 
cervical  caries,  when  it  may  extend  downwards  into  the 
mediastinum  or  pleural  cavity ;  but  the  abscess  should 
never  be  allowed  to  open  itself,  as  it  has  been  known  to 
cause  instant  death  by  discharging  its  contents  into  the  air- 
passages  during  sleep,  or  from  haemorrhage  by  ulcerating 
into  the  large  blood-vessels  of  the  neck.  Broncho-pneu- 
monia and  oedema  of  the  glottis  are  the  most  frequent 
complications  in  ordinary  cases. 

Treatment. — The  treatment  consists  in  opening  the 
abscess  through  the  neck,  either  by  Chiene's  incision  along 


NON-TUBERCULOUS    INFECTIVE    DISEASES        2  J 

the  posterior  border  of  the  sterno-mastoid,or  by  Burckhardt's 
incision  along  the  anterior  border  of  the  muscle.  I  prefer 
the  former  method.  A  one-inch  incision  is  commenced 
an  inch  below  the  mastoid  process  and  immediately  behind 
the  posterior  border  of  the  stemo-mastoid.  The  knife  is 
laid  aside  as  soon  as  the  deep  fascia  has  been  divided,  and 
the  abscess  is  opened  with  a  blunt-pointed  director,  one 
finger  being  kept  in  the  mouth  touching  the  back  wall  of 
the  pharynx.  The  abscess  is  readily  emptied  by  pressure 
exercised  through  the  pharynx  ;  but  care  must  be  taken  to 
empty  any  pouches  which  may  extend  downwards.  The 
proof  of  having  done  this  successfully  is  the  marked  im- 
provement taking  place  in  the  respiration.  The  abscess 
cavity  is  well  washed  out  and  a  drainage-tube  is  inserted, — 
for  I  have  not  yet  ventured  to  scrape  and  try  to  obtain  union 
by  first  intention, — the  ordinary  dressings  are  applied, 
and  the  child  in  uncomplicated  cases  usually  does  well. 
It  sometimes  happens  that  the  dyspnoea  is  so  urgent  that 
it  is  necessary  to  perform  tracheotomy,  and  when  this  is 
requisite,  the  low  operation  is  said  to  be  preferable  to  the 
high.  The  after-treatment  consists  in  keeping  the  child  in 
bed  with  its  head  fixed  until  the  wound  has  healed,  and  in 
giving  plenty  of  good  food. 

The  older  operation  of  opening  the  abscess,  by  an  incision 
carried  through  its  whole  extent  in  the  pharynx,  would  not, 
I  think,  give  such  satisfactory  results,  though  it  is  still 
recommended  by  some  surgeons,  as  the  bleeding  and  the 
discharge  of  pus  in  a  patient  whose  respiration  is  already 
greatly  impeded,  renders  it  dangerous,  quite  apart  from  the 
fact  that  after  such  an  operation  the  abscess  cannot  be 
kept  aseptic.  It  is  possible,  however,  that  cases  might 
arise  in  which  such  a  method  of  opening  would  be  more 
advisable  than  that  of  incising  through  the  neck.  Aspira- 
tion in  these  cases  should  not  be  attempted. 


28        THE    SURGICAL    DISEASES    OF    CHILDREN 

ACTINOMYCOSIS. 

^Etiology. — Actinomycosis  is  a  rare  disease  sometimes 
affecting  children,  for  I  saw  Dr.  Douglas  Powell's  5  patient, 
a  boy  of  nine.  It  is  due  to  the  invasion  of  the  tissues  by  a 
fungus,  sometimes  derived  by  inoculation  from  cattle,  but 
more  often  perhaps  from  infected  grain.  The  exact  method 
of  introduction  is  doubtful,  but  it  probably  gains  entrance 
by  the  respiratory  passages,  and  in  a  few  rare  instances 
by  the  mouth,  through  carious  teeth. 

Pathology. — The  actinomyces  fungus  has  a  character- 
istic appearance  which  'allies  it  to  streptothrix.  It  consists 
of  a  mycelium  associated  with  a  considerable  quantity  of 
inflammatory  granulation  tissue.  The  mycelium  is  sur- 
rounded by  a  fringe  of  clubs  arranged  radially,  which 
has  led  to  its  name  of  "  ray  fungus."  Only  the  most 
typical  specimens  terminate  in  these  clubs  or  cocci,  whose 
significance  is  still  unknown.  The  younger  nodules  in 
man  rarely  show  the  club-shaped  extremities,  whilst  the 
older  nodules  often  lose  their  central  mycelial  mass  and 
become  crescentic  in  shape.  The  growth  spreads  by  con- 
tinuity from  tissue  to  tissue,  it  sets  up  local  irritation, 
leads  to  extensive  suppuration,  and  may  cause  pyaemie 
symptoms. 

Symptoms. — The  symptoms  are  those  of  a  chronic 
abscess  affecting  the  skin,  mucous  membranes,  bones  or 
viscera,  especially  the  lungs  and  liver.  It  appears  on  the 
skin  in  the  form  of  numerous  globular  masses  which  are 
soft  and  spongy  and  have  an  indurated  erythematous  base. 
Dr.  Pringle's  case,  occurring  in  a'  boy  of  thirteen  years, 
presented  large,  sarcomatous-looking  growths,  ulcerating 
at  various  points,  situated  upon  hard,  brown  and  deeply 
undermined  skin.  From  the  ulcerating  points  pus  exuded, 
mixed  with  characteristic  yellow  granules  which  were 
recognised  under  the  microscope  as  colonies  of  actinomyces. 


NON-TUBERCULOUS    INFECTIVE    DISEASES        29 

Diagnosis.— It  is  found  that  the  abscess  either  consists 
of  caseating  substance,  or  of  a  semi-fluid,  brain-like  mate- 
rial mixed  with  blood.  It  is  therefore  most  likely  to  be 
mistaken  for  a  chronic  tuberculous  abscess,  for  a  sarcoma, 
or  for  an  empyema.  The  pus,  however,  is  gritty,  and  close 
examination  reveals  that  the  grittiness  is  due  to  minute 
nodules  just  visible  to  the  naked  eye  and  readily  seen  as 
rounded  masses  under  a  low  power  of  the  microscope,  con- 
sisting of  colonies  of  the  ray  fungus.  In  cases  of  suspected 
actinomycosis,  Gram's  method  of  staining,  applied  to  a 
coverglass  px*eparation  of  the  colonies  obtained  from  the 
pus,  will  easily  demonstrate  the  typical  masses  of  branch- 
ing mycelium.  The  clubs  may  be  shown,  if  they  are 
present,  by  first  staining  a  crushed  nodule  with  hsema- 
toxylin,  and  then  with  acid  fuchsin.  They  will  be  found 
scattered  over  the  field  of  the  microscope,  and  not  arranged 
in  definite  circles. 

Prognosis. — The  disease  runs  a  very  chronic  course,  as 
it  may  last  for  months  or  even  for  years  ;  when  it  sets  up 
a  pleurisy,  the  effusion  may  be  absorbed. 

Treatment. — The  treatment  consists  in  attacking  the 
individual  nodules,  thoroughly  removing  them,  and  by 
afterwards  applying  chloride  of  zinc  in  solution. 


INFECTIVE   OSTEITIS. 

Inflammatory  diseases  of  bone  have  long  been  known  in 
association  with  the  exanthemata.  The  inflammation  is 
an  osteomyelitis,  but  the  stress  of  the  disease  may  fall, 
either  upon  the  deeper  layers  of  the  periosteum  and  lead 
to  its  separation  or  to  its  increased  functional  activit}',  or 
it  may  fall  upon  the  bone  itself,  leading  to  sclerosis,  local 
or  general,  suppuration,  or  to  its  rarefaction.     Pathology 


30        THE    SURGICAL    DISEASES    OF    CHILDREN 

does  not  yet  tell  us  why  these  changes  take  place.  It 
may  be  that  they  are  associated  with  the  infective  micro- 
organisms themselves ;  it  may  be  that  they  are  due  to  the 
poisonous  products  of  their  activity ;  it  is  more  likely  that 
they  result  from  the  action  of  separate  organisms  and  that 
the  exanthematous  germs  merely  prepare  the  way  before 
them.  The  inflammation  takes  place  in  those  parts  of  the 
bone  tissues  which  are  the  most  vascular,  and  in  which  the 
most  elaborate  developmental  changes  are  going  on.  They 
are  therefore  most  often  seen  in  the  neighbourhood  of  the 
epiphyses  and  in  the  jaws.  Acute  osteomyelitis  for  the 
present  must  be  looked  upon  as  a  mere  clinical  term,  which 
in  the  course  of  a  few  years  we  shall  be  able  to  replace  by 
a  series  of  groups  capable  of  being  distinguished  one  from 
another,  and  perhaps  capable  of  individual  treatment.  The 
question  at  present  is  one  of  transcendental  pathology, 
and  though  it  is  of  the  greatest  interest,  it  need  not  longer 
detain  us. 

Acute  Osteomyelitis. 

Pathology. — In  only  a  few  instances  has  pathological 
work  borne  such  good  fruit  as  that  connected  with  the 
causation  of  acute  osteomyelitis,  which  in  its  later  stages 
was  known  as  "  acute  necrosis."  Our  knowledge  of  this 
most  serious  affection  is  now  founded  upon  so  firm  a  basis 
of  facts,  acquired  by  experimental  methods,  that  its 
modern  treatment  is  no  longer  empirical.  The  first 
great  advance  in  our  knowledge  was  the  recognition  of  the 
important  fact  that  osteomyelitis  was  an  infective  disease 
due  to  a  micrococcus.  The  second,  that  there  was  no  specific 
micrococcus  producing  it,  but  that  a  variety  of  different 
forms  might  give  rise  to  that  group  of  clinical  signs  and 
symptoms  which  in  the  aggregate  is  called  acute  osteo- 
myelitis or  acute  septic  osteitis.     The  third  great  step  in 


NON-TUBERCULOUS    INFECTIVE    DISEASES       3  I 

advance  was  made  on  the  discovery  that  the  micrococci 
were  not  necessarily  introduced  directly  into  the  bone,  but 
that  they  often  gain  access  through  some  other  portal. 
This  discovery  at  once  coreelated  experimental  work  with 
clinical  experience,  for  it  had  been  long  known  that  the 
worst  cases  of  this  disease  occurred  after  the  exanthemata, 
the  exciting  cause  often  being  the  most  trivial  injury. 

etiology. — It  is  therefore  obvious  that  in  septic  osteo- 
myelitis, as  in  all  other  infective  diseases,  there  must  be  a 
proper  soil  for  the  growth  of  the  organism,  and  this  is 
known  as  the  predisposition  to  the  disease.  There  must 
be  the  organism  itself,  which  in  this  case  is  circulating 
through  the  blood,  and  so  far  as  can  be  ascertained,  is 
daily  being  absorbed  by  the  various  mucous  membranes 
which  for  some  reason  have  failed  to  perform  their  protec- 
tive functions.  Lastly,  there  must  be  a  place  of  least 
resistance  where  the  organisms  which  have  thus  gained 
access  to  the  body  may  settle  and  multiply.  All  these 
factors  are  found  in  cases  of  acute  osteomyelitis.  The 
child  is  nearly  always  in  a  debilitated  condition,  as  it  has 
recently  passed  through  an  attack  of  measles,  scarlet  fever, 
influenza,  whooping  cough  or  pneumonia,  all  diseases 
associated  with  the  presence  of  specific  micro-organisms. 

Exciting  Causes. — A  slight  injury  to  one  of  the  bones, 
or  the  mere  application  of  cold  to  a  limb,  may  set  up 
sufficient  vascular  disturbance  to  fit  the  part  to  act  as  a 
nidus  for  the  organism,  and  the  disease  is  started.  The 
excellent  scientific  work  which  has  been  done  by  the  Lyons 
School  of  Medicine  has  shown  how  complex  are  the  changes 
which  take  place  at  the  epiphyseal  line  of  a  growing  bone ; 
80  that  we  have  no  difficulty  in  understanding  why  the 
micro-organism,  in  cases  of  acute  osteomyelitis,  usually 
shows  so  great  a  preference  for  this  part  of  the  bone,  that 
many  surgeons  have  proposed,  but  unadvisedly,  to  call  the 


32         THE    SURGICAL    DISEASES    OF    CHILDREN 

disease  by  the  name  of  epiphysitis.  The  developmental 
processes  lead  to  the  formation  of  many  new  blood-vessels, 
some  of  which  are  still  cul-de-sacs ;  so  that  the  micro- 
organisms remaining  in  the  stagnant  blood-stream  are  able 
to  exercise  their  full  powers  for  evil,  by  leading  to  an 
emigration  of  leucocytes.  The  disease,  as  it  is  well  known, 
occurs  in  children — boys  usually — from  the  time  of  birth 
until  the  union  of  the  epiphyses  has  taken  place ;  but  it  is 
less  frequent  in  the  later  than  in  the  earlier  years  of  child- 
hood. It  most  often  attacks  the  lower  end  of  the  femur 
and  upper  end  of  the  tibia,  more  frequently  bones  which 
are  subcutaneous  than  those  which  are  well  covered  (though 
the  flat  cranial  bones  are  an  exception  to  this  rale,  for  they 
are  rarely  affected).  Bones  which  grow  rapidly  are  more 
liable  to  be  attacked  than  those  which  grow  slowly.  It  is 
therefore  most  frequent  in  the  femur  and  tibia,  and  it  is 
least  often  seen  in  the  lower  jaw  and  clavicle. 

Varieties. — Septic  osteomyelitis  is  met  with  in  two 
forms  :  circumscribed  when  its  effects  are  limited  to  the 
immediate  neighbourhood  of  the  part  in  which  it  starts, 
and  diffuse  when  large  tracts  of  tissue  are  involved.  The 
worst  possible  results  ensue  from  the  diffuse  form.  Mr. 
Pick  has  recently  pointed  out  that  in  children  under  one 
year,  acute  osteomyelitis  is  usually  an  inflammation  of 
the  young  growing  bone  beneath  the  epiphyseal  line,  and 
as  the  epiphysis  is  cartilaginous  and  thin,  the  neighbour- 
ing joint  is  very  frequently  directly  involved  in  the  in- 
flammation ;  whilst  in  older  children,  the  epiphysis  being 
less  cartilaginous  and  thicker,  the  joint  may  escape,  for  the 
abscess  may  open  externally.  In  these  older  children,  if 
the  joint  does  become  involved  it  is  by  a  different  process, 
for  the  inflammatory  products  do  not  pass  directly  through 
the  epiphysis,  as  in  the  previous  case,  but  the  whole  limb 
being  in  a  condition  of  cellulitis  the  inflammation  tracks 


NON-TUBERCULOUS    INFECTIVE    DISEASES       $$ 

round  by  the  periosteum,  and  then  enters  at  the  periphery 
of  the  articulation,  instead  of  through  its  centre. 

The  Symptoms  of  acute  osteomyelitis  are  those  of  a 
more  or  less  severe  attack  of  septicaemia,  but  they  differ 
somewhat  with  the  age  of  the  child,  though  in  the  worst 
forms  death  may  take  place  before  any  coarse  bone 
lesion  is  found.  In  very  young  children,  in  whom  pain 
is  neither  felt  acutely  nor  localised  definitely,  the  symp- 
toms are  ill-defined.  The  child  is  noticed  to  be  ailing, 
and  refuses  its  food.  It  is  fretful,  and  screams  when 
it  is  dressed  or  moved.  Careful  and  prolonged  observation 
will  show  that  one  limb  is  kept  motionless,  and  if  this  part 
be  examined,  pain  can  be  elicited  by  even  moderate  pressure, 
the  tender  spot  being  situated  near  one  of  the  epiphyses. 
If  these  symptoms  pass  unnoticed,  or  are  allowed  to  go 
untreated,  the  joint  often  becomes  suddenly  and  acutely 
inflamed,  for  an  abscess  bursts  into  it,  and  the  child  is 
then  brought  to  the  surgeon  for  treatment.  The  disease 
sometimes  runs  a  less  severe  coiirse,  the  epiphyses  remain 
enlarged,  but  no  acute  abscess  is  formed.  In  other  cases, 
again,  the  abscess  tracks  upwards  or  downwards  into  the 
soft  tissues,  and  the  joint  escapes  the  full  force  of  the 
disease ;  but  these  cases  are  less  frequent  in  very  young 
children. 

Acute  osteomyelitis  runs  its  most  typical  course  in 
children  over  two  years  of  age,  though  it  is  commonly  seen 
between  the  ages  of  nine  and  fifteen  years.  It  begins 
suddenly  in  a  delicate  or  debilitated  child  with  a  convul- 
sion, or  more  rarely  a  rigour,  vomiting,  diarrhoea,  or  severe 
headache.  The  child  only  complains  of  pain  near  a  joint  if 
it  be  questioned,  for  it  is  often  too  ill  to  do  so  spontaneously. 
Its  temperature  rises  rapidly  to  105°  or  106°  F.,  with  morn- 
ing remissions  to  102°  F.,  and  he  often  becomes  delirious. 
He  now  presents  all  the  symptoms  of  acute  septic  poisoning. 

D 


34        THE    SURGICAL    DISEASES    OF    CHILDREN 

His  tongue  is  dry,  lie  has  diarrhoea,  he  sweats  profusely, 
his  spleen  is  enlarged,  his  urine  contains  albumin,  and  he 
often  has  a  little  bronchitis.  The  tacttis  eruditus  will 
alone  detect  the  bone  lesion  during  the  first  two  days  of 
the  illness,  and  even  that  sometimes  fails ;  but  in  the  later 
stages,  when  the  time  for  cure  has  passed,  it  is  obvious 
that  the  bone,  and  perhaps  the  joint,  is  extensively 
diseased.  A  diffuse  abscess,  filled  with  purulent  and 
blood-stained  fluid,  has  formed,  and  a  sequestrum  of 
greater  or  less  extent  must  be  the  result. 

The  Differential  Diagnosis  is  of  the  very  greatest  im- 
portance, for  there  are  few  diseases  in  which  so  much  can 
be  done  in  the  early  stages,  and  so  little  in  the  later  ones. 
There  are  few  diseases,  too,  in  which  a  mistaken  diagnosis 
is  more  common.  The  acuteness  of  the  onset  usually  leads 
the  practitioner  to  think  of  the  acute  diseases  with  which 
he  meets  more  frequently  than  acute  osteomyelitis.  He 
therefore  attributes  the  attack  to  acute  rheumatism,  to 
cellulitis,  to  the  onset  of  one  of  the  exanthemata,  to  tuber- 
culous peritonitis  or  meningitis,  to  typhoid  fever,  or  even  to 
scurvy,  and  in  this  way  much  precious  time  is  lost.  It 
should  be  a  matter  of  routine  to  examine  the  limbs  in  all 
cases  of  acute  illness  occurring  in  growing  children,  and  a 
moment's  examination  will  eliminate  everything  except 
articular  rheumatism.  Mr.  Edmund  Owen  has  recently 
drawn  attention  to  the  fact  that  in  the  early  stages  acute 
osteomyelitis  near  the  knee  may  be  distinguished  from 
rheumatism  by  gently  moving  the  limb,  and  observing  that 
the  joint  is  normal,  and  that  the  inflammation  affects  the 
deeper  tissues  above  or  below  it ;  whilst  in  the  later  stages, 
before  an  abscess  has  formed,  there  is  a  tender  swelling  of 
the  ends  of  the  bone,  which  is  felt  most  readily  by  putting 
a  finger  and  thumb  upon  either  side  of  the  bone  and  com- 
paring it  with  the  corresponding  part  on  the  opposite  side. 


NON-TUBERCULOUS    INFECTIVE    DISEASES       35 

The  confusion  of  rheumatism  with  septic  disease  is  no 
doubt  due  to  the  pernicious  habit  acquired  by  English 
practitioners  of  calling  infective  arthritis  in  all  its  forms 
rheumatism,  instead  of  speaking  in  precise  pathological 
language  of  gonorrhoea!  arthritis,  scarlatinal  arthritis,  and 
other  similar  forms. 

The  Prognosis  of  acute  osteomyelitis,  unless  it  be  seen 
in  its  very  earliest  stages,  is  always  grave.  Death  of  the 
affected  bone,  to  a  greater  or  less  extent,  is  the  rule ;  the 
joint  may  become  involved,  or  the  infective  process  may 
spread  throughout  the  body,  so  that  the  patient  dies  with 
pysemic  symptoms.  If  he  escapes  the  immediate  risks  of 
the  acute  stage,  he  may  succumb  to  the  remote  effects  of 
a  long-continued  suppuration,  in  the  endeavour  to  cast 
off  large  pieces  or  even  the  whole  shaft  of  bone  which 
has  died.  Recent  improvements  in  surgery,  by  timely 
operation,  have  materially  lessened  the  number  of  deaths 
due  to  diarrhoea,  lardaceous  disease  and  exhaustion. 

Operative  Treatment  must  be  adopted  in  every  case  as 
soon  as  the  disease  is  recognised,  and,  if  possible,  before  an 
abscess  has  been  formed.  The  limb  should  be  rendered  blood- 
less by  elevation  and  the  application  of  a  rubber  bandage. 
One  or  more  incisions  should  be  made  at  once  through  any 
tender  swelling  right  down  upon  the  bone,  and  under  no 
circumstances  should  the  incision  be  deferred  until  fluctua- 
tion can  be  detected.  Good  will  have  been  done  to  the 
patient  even  though  nothing  but  blood  escapes,  for  tension 
will  have  been  abolished.  The  wound  in  these  cases  must 
not  be  closed,  it  should  be  packed  with  aseptic  gauze  and 
allowed  to  granulate.  A  thorough  examination  on  either 
side  of  the  epiphyseal  line  should  be  made  by  means  of 
a  probe  if  pus  be  found.  Any  opening  in  it  should  be 
enlarged  with  a  gouge  or  burr,  and  the  cavity  into  which 
it  leads  should  be  thoroughly  scraped  to  remove  all  granu- 


36        THE    SURGICAL    DISEASES    OF    CHILDREN 

lation  tissue.     Care  must  be  taken  in  doing  this  that  the 
joint  be  not  opened,  and  that  the  compact  tissue  is  not 


Fig.  2.— Photograph  of  a  child  who  had  a  large  drainage-tube  passing  from 
A  through  her  shoulder-joint  for  twenty-eight  days.  It  shows  the  free 
movement  which  often  occurs  in  children's  joints,  even  after  prolonged 
suppuration. 

unduly  encroached  upon.  The  cavity  thus  cleaned  should 
be  swabbed  out  with  a  1  in  15  solution  of  zinc  chloride, 
thoroughly  irrigated   with  a  saturated  solution   of  boric 


NON-TUBERCULOUS    INFECTIVE    DISEASES         T>7 

acid,  and  packed  with  gauze,  no  attempt  being  made  to 
close  the  wound. 

Attention  should  be  directed  to  the  shaft  of  the  bone, 
if  the  epiphysis  appears  to  be  unaffected  and  there  is  no 
pus  beneath  the  periosteum.  The  guarded  use  of  a  drill, 
gouge,  or  trephine,  will  sometimes  reveal  the  presence  of 
suppuration  within  the  bone.  The  compact  tissue  in  these 
cases  should  be  gotiged  away,  and  the  same  treatment 
employed  as  has  been  recommended  for  the  epiphysis. 
The  joint  in  cases  of  secondary  arthritis  should  be  laid 
open,  thoroughly  washed  out,  and  freely  drained.  It 
should  be  dressed  antiseptically,  and  fixed  immovably  in 
the  position  which  is  the  most  likely  to  give  a  useful  limb 
in  case  there  is  subsequent  anchylosis.  The  reparative 
power  in  children  is  so  great,  however,  that  the  recovery 
with  a  useful  joint  is  not  to  be  despaired  of  even  in  what 
appears  to  be  the  least  hopeful  case  at  the  time  of  the 
operation.  The  following  instance  shows  how  useful  a  limb 
may  be  obtained  after  the  most  severe  treatment  of  a 
joint.  It  also  shows  that  free  and  prolonged  drainage 
of  a  joint  does  not  of  necessity  lead  to  its  anchylosis. 
The  details  were  briefly  as  follows  : — 

E.  M.,  aged  4J,  fell  upon  the  back  of  a  chair,  striking 
her  left  axilla,  on  February  12,  1894.  She  complained 
of  pain  in  the  shoulder,  and  a  week  later  a  large  abscess 
was  found  in  the  armpit.  The  abscess  was  incised,  three 
ounces  of  pus  were  let  out,  and  its  cavity  was  scraped. 
As  it  was  connected  with  the  shoulder- joint,  a  counter- 
incision  was  made  over  the  head  of  the  humerus.  The 
upper  part  of  the  shaft  of  the  bone  was  felt  to  be  bare,  and 
a  drainage-tube  was  passed  through  the  joint  from  one 
opening  to  the  other.  The  joint  and  the  cavity  of  the 
abscess  were  then  irrigated  with  boric  lotion,  and  a  dress- 
ing of  cyanide  gauze  was  applied.     The  tube  was  retained 


3%        THE    SURGICAL    DISEASES    OF    CHILDREN 

in  the  wound  from  February  12  to  March  11,  and  four 
days  later  the  child  was  sent  to  her  friends.  She  came  to 
see  me  on  August  27,  1894,  and  I  had  her  photographed. 


Fig.  3.— The  right  femur  of  a  child.     The  lower  half  of  the  shaft  is  greatly 
enlarged,  as  a  result  of  suppurative  periostitis  of  an  unusual  character. 

[From  a  drawing  in  the  Museum  of  St.  Bartholomew's  Hospital.] 

She  has  absolutely  free  movement  of  her  shoulder  in  every 
direction,  and  the  left  arm  appears  to  be  in  every  respect 
as  useful  as  the  other  (see  fig.  2). 


NON-TUBERCULOUS    INFECTIVE    DISEASES 


The  remarkable  changes  which  sometimes  result  from  a 
stripping  off  of  the  periosteum  are  well  seen  in  the  annexed 
drawings  (see  figs.  3  and  4)  from  a  specimen  in  the 
Museum  of  St.  Bartholomew's  Hospital.  The  bone  is  ex- 
panded in  its  lower  half,  and  the  sections  show  the  original 
shaft  lying  in  the  centre  of  a  cavity  with  bony  walls.  The 
space  between  the  bony  shaft  and  the  inner  edge  of  the 
wall  of  this  cavity  measures  five-eighths  of  an  inch,  and 


Fig.  i.— Transverse  sections   through  the   enlarged  portion   of   the   femur 
represented  in  fig.  3.     The  increase  in  the  size  of  the  shaft  is  seen  to  be  due 
to  a  thick  ring  of  new  bone,  separated  from  the  shaft  by  a  considerable  space. 
[From  Specimen  No.  39  (b)  in  the  Museum  of  St.  Bartholomew's  Hospital.^ 

a  few  irregular  fibrous  bands  extend  across  it.  It  con- 
tained pus  when  it  was  first  opened.  This  peculiar 
appearance  seems  to  be  due  to  the  fact  that  the  periosteum 
was  separated  from  the  shaft  by  an  acute  inflammation 
which  involved  it  without  destroying  its  functions.  The 
intervening  space  became  filled  with  pus,  and  the  inner 
la}^er  of  the  periosteum  formed  a  layer  of  bone  round  it. 
The  child,  aged  one  year,  had  only  been  ill  a  month  before 
he  died  of  bronchitis  complicated  by  laryngitis.  He  had 
never  been  strong  or  healthy,  but  he  had  no  symptoms  of 


4-0        THE    SURGICAL    DISEASES    OF    CHILDREN 

scurvy  or  rickets.  The  legs  were  swollen  and  oedematous. 
The  lower  part  of  each  thigh  was  greatly  swollen,  but 
there  was  no  effusion  into  the  joints.  The  outer  side  of 
the  right  femur  fluctuated,  and  pus  was  let  out  through 
an  incision  made  seventeen  days  before  death. 

NON-SUPPURATIVE   OSTEOMYELITIS. 

An  analogous  condition  is  sometimes  met  with  in  older 
children,  in  whom  the  osteomyelitis  runs  a  sub-acute 
course.  It  is  associated  with  the  presence  of  the  staphylo- 
coccus pyogenes  albus,  and  is  known  under  the  name  of 
periostitis  albuminosa.  The  inflammation  usually  com- 
mences near  the  epiphyses  of  one  of  the  long  bones,  and 
leads  to  the  formation  of  a  swelling,  which  is  tender,  and 
contains  a  serous  fluid  with  mucus  and  fat.  This  form 
can  be  distinguished  from  the  ordinary  osteomyelitis,  by 
its  slow  course,  by  the  slight  constitutional  symptoms  to 
which  it  gives  rise,  and  by  the  small  extent  to  which  the 
bone  is  involved.  The  treatment  consists  in  cutting  down 
upon  the  swelling  and  scraping  away  its  contents.  It 
seems  to  be  the  result  of  an  attenuated  virus. 

Typhoidal  Osteomyelitis. 

A  still  rarer  form  of  osteomyelitis  is  now  beginning  to 
be  recognised  as  one  of  the  sequelse  of  typhoid  fever. 

^Etiology. — The  inflammation  is  rarely  purulent,  and  it 
seems  to  be  always  associated  with  the  presence  of  typhoid 
bacilli,  which  disappear  if  suppuration  occurs. 

Symptoms. — Severe  pain  is  felt  in  the  affected  part 
usually  during  the  second  or  third  week  of  convalescence 
from  typhoid  fever.  The  pain  is  worse  at  night,  and 
when  the  part  is  dependent.  It  most  often  affects  the 
lower  limbs  and  the  vertebral  column.  A  doughy  ox- 
elastic  tumour  after  a  time  develops  at  the  seat  of  the 


NON-TUBERCULOUS    INFECTIVE    DISEASES        4 1 

pain.     The  temperature  is  raised,   and  it  may  be  of  the 
hectic  type.     There  may  be  considerable  wasting. 

Course. — The  swelling  may  be  absorbed,  leaving  a  tem- 
porary periostitis.  Its  contents  may  caseate,  and  it  may 
then  open  spontaneously.  In  some  cases  it  liquefies, 
when  the  surface  of  the  bone  may  become  affected,  or  a 
sequestrum  may  be  produced. 

Treatment. — The  treatment  consists  in  cutting  down 
upon  the  swelling  before  it  has  undergone  secondary 
changes.  Its  contents  should  be  removed  with  a  sharp 
spoon,  and  an  attempt  should  be  made  to  get  union  by 
first  intention. 

Sequelae  of  Suppurative  Osteomyelitis. — Necrosis 
does  not  often  take  place,  even  in  the  most  acute  forms 
of  septic  osteomyelitis,  for  some  days  after  the  onset  of  the 
symptoms.  Dr.  Macewen  points  out  that  the  bone  dies  as 
a  whole  when  the  periosteum  is  raised  from  the  shaft  and 
the  nutrient  vessels  either  become  occluded  by  thrombosis 
or  embolism,  or  are  ruptured.  Superficial  necrosis,  on  the 
other  hand,  occurs  when  the  periosteal  blood  supply  is  cut 
off  from  the  portions  of  the  shaft  of  the  bone,  whilst  the 
nutrient  arteries  remain  intact.  When  the  bone  has  been 
exposed  in  a  case  of  osteomyelitis  it  is  often  found  to  be 
white  and  bare,  and  if  the  nutrient  arteries  are  intact  it 
gradually  becomes  covered  with  granulations,  but  if  they 
are  blocked  the  bones  remain  white.  The  signs  denoting 
the  presence  of  a  sequestrum  are  often  obscure,  especially 
if  it  lies  deeply  in  the  bone,  for  it  is  then  likely  to  be 
mistaken  for  a  new  growth  in  the  bone.  There  is  usually 
no  difficulty  in  detecting  dead  bone  when  it  lies  loose  at 
the  bottom  of  a  sinus  whose  orifice  is  guarded  by  a  mass 
of  granulation  tissue.  Its  presence  can  only  be  guessed 
at  when  there  is  no  sinus,  in  cases  where  after  an  attack 
of  osteomyelitis  the  bone  is  enlarged,  thickened  and  pain- 


42         THE    SURGICAL    DISEASES    OF    CHILDREN 

ful,  for  chronic  osteitis  may  produce  a  similar  condition. 
A  cautious  surgeon  will  therefore  hesitate  to  perform  an 
operation  for  the  removal  of  a  sequestrum  unless  he  has 
clear  evidence  of  its  presence,  or  unless  the  suppuration 
is  so  extensive  as  to  threaten  the  advent  of  lardaceous 
disease.  It  is  sometimes  necessary  to  remove  the  dead 
bone  as  soon  as  possible  when  the  whole  diaphysis  has 
perished,  especially  if  it  be  the  radius,  ulna,  or  fibula  ;  but 
caution  must  be  exercised  in  the  case  of  the  tibia,  femur, 
and  humerus.  It  sometimes  happens,  if  the  bone  be  too  early 
removed,  that  the  osteogenetic  properties  of  the  periosteum 
are  not  sufficiently  developed  to  form  an  entire  new  shaft, 
even  with  the  assistance  of  the  epiphyses,  and  an  insecure 
limb  results.  When  this  happens,  means  must  be  taken 
to  stimulate  the  inner  layer  of  the  periosteum  by  the 
introduction  of  foreign  bodies,  which  will  remain  aseptic. 
It  is  generally  wise  to  allow  an  interval  of  two  months 
to  elapse  in  the  upper  extremity,  and  three  months  in  the 
lower,  before  attempting  to  remove  an  extensive  seques- 
trum, and  in  the  meantime  free  drainage  must  be  allowed, 
and  the  limb  should  be  kept  at  rest  upon  a  splint. 

Treatment  of  Sequestra.— A  sequestrum  is  removed 
either  as  a  whole  or  piecemeal  as  soon  as  it  is  felt  to  be 
loose.  The  child  is  ansesthetissd  for  this  purpose,  its  limb 
is  rendered  bloodless  by  means  of  an  Esmarch's  bandage, 
and  the  sinus  is  enlarged,  the  cloaca  is  then  explored  and 
gouged  away  until  the  sequestrum  can  be  withdrawn  with 
a  pair  of  strong  forceps.  The  gouge  has  often  to  be  supple- 
mented by  cutting  forceps,  Hey's  saw,  or  a  trephine.  The 
cavity  in  which  the  sequestrum  lay  is  thoroughly  scraped 
until  pink  bone  is  reached  and  until  blood  oozes  from  the 
Haversian  canals.  The  diseased  skin  and  the  granulation 
tissue  at  the  orifice  of  the  sinus  is  also  scraped  away,  and 
all  the  parts  are  swabbed  with  a  solution  of  chloride  of 


NON-TUBERCULOUS    INFECTIVE    DISEASES       43 

zinc  (15  grains  to  the  ounce),  and  afterwards  flushed  with 
warm  boric  lotion.  The  cavity  is  then  packed  with  dry 
gauze,  or  in  very  young  children  the  gauze  is  moistened 
with  camphorated  naphthol,  and  the  wound  is  allowed  to 
granulate  from  the  bottom  :  a  process  which  takes  several 
weeks.  The  secretions  must  not  be  allowed  to  collect  in 
the  wound,  and  repeated  dressings  are  therefore  necessary. 
In  children  it  is  only  necessary  to  amputate  the  limb  in 
very  exceptional  cases. 

Rarefaction  and  Sclerosis  of  Bone. 
Sinuses  discharging  a  thin  pus,  unhealthy  scars  showing 
a  constant  tendency  to  break  down  upon  slight  provocation, 
and  residual  abscesses  are  very  frequent  sequelse  of  an 
attack  of  osteomyelitis.  So  frequent  and  so  well  known 
are  these  sequelae  that  the  tragedian  made  Philoctetes 
suffer  from  such  an  issue  in  that  play  which,  though  it  is 
not  the  greatest  of  its  author's  creations,  has  yet  an  abiding 
interest  for  the  surgeon,  for  it  depicts  a  case  of  infective 
osteomyelitis  terminating  in  sclerosis  as  it  was  presented 
to  an  Athenian  audience  2,400  years  ago.  The  treatment 
in  all  cases  consists  in  cutting  down  upon  the  inflamed 
spot,  and  drilling  the  bone  towards  the  epiphysis  in  those 
cases  where  there  is  much  pain  apparently  associated  with 
circumscribed  collections  of  pus.  The  bone  must  be  tre- 
phined if  pus  is  found,  and  the  abscess  is  then  treated  in 
the  same  way  as  the  sequestrum  cavity.  The  carious 
bone  is  gouged  away  if  a  discharging  sinus  remains,  and 
the  wound  is  allowed  to  heal  under  antiseptic  dressings. 

WHITLOW. 

The  term  whitlow  is  clinical  rather  than  scientific,  and 
it  is  employed  loosely  to  denote  any  infective  inflammation 
affecting  the  tissues  of  the  fingers.     It  is  one  of  the  most 


44         THE    SURGICAL    DISEASES    OF    CHILDREN 

troublesome  and  painful  of  the  minor  affections  to  which 
children  are  liable. 

Varieties  and  etiology.— (1)  In  its  simplest  form 
it  is  a  localised  inflammation  of  the  skin  of  the  finger, 
the  result  of  direct  inoculation  after  a  slight  injury. 

(2)  The  superficial  or  subcutaneous  whitlow  is  generally 
found  about  the  nail  and  the  finger-tips  of  children  who 
are  thoroughly  out  of  health,  or  in  those  who  have  recently 
suffered  from  one  of  the  exanthemata.  It  is  often  associated 
with  eczematous  patches  upon  other  parts  of  the  body. 

(3)  A  whitlow  may  run  the  ordinary  course  of  a  case  of 
infective  osteomyelitis,  terminating  in  the  death  of  one 
of  the  phalanges,  usually  the  terminal  one,  though  either 
of  the  others  may  be  affected.  It  follows  a  slight  blow 
or  sprain,  or  it  may  be  produced  by  a  punctured  wound. 

(4)  The  most  severe  form  of  whitlow  is  that  known  as 
the  thecal  abscess.  It  is  formed  inside  the  sheath  of  the 
flexor  profundus  digitorum  tendons.  It  is  an  infective 
inflammation,  originating  like  the  other  forms  in  a  very 
slight  puncture  or  in  a  poisoned  wound. 

(5)  Painless  whitlow  is  a  rare  form  occurring  in  syringo- 
myelia. It  is  of  trophic  origin,  and  was  first  described  by 
Morvan.  It  is  said  to  run  a  chronic  and  painless  course, 
and  may  lead  to  complete  destruction  of  the  terminal 
phalanx. 

Symptoms.— The  symptoms  in  the  slightest  cases  are 
local  pain,  followed  in  the  course  of  a  few  hours  by  redden- 
ing of  the  skin  without  any  great  swelling. 

The  subcutaneous  whitlow  causes  much  pain,  with 
localised  tenderness  and  inflammation.  The  finger-tip  is 
not  much  swollen,  but  a  blister  is  formed  upon  it  usually 
of  considerable  size,  and  often  produced  upon  more  than  one 
phalanx.  The  blisters  are  opaque,  and  contain  a  purulent 
fluid. 


NON-TUBERCULOUS    INFECTIVE    DISEASES        45 


Diagrams  showing  the  usual  and  the  commoner  forms  of 
irregular  arrangement  of  tendon  sheaths  in  the  hand 
(from  Testufs  Anatomie  Humaine). 

A     S       R 


Fig.  5. — Diagram  showing  the  ordinary  arrangement  of  sheaths  of  the  flexor 
tendons  of  the  forearm  (from  Testut's  Traiti  a" Anutomie  Humaine).  A,  radius  ; 
B,  ulna ;  /.,  //.,  III.,  IV.,  V.,  indicate  the  thumb  with  the  index,  middle,  ring, 
and  little  fingers  respectively;  1,  the  external  carpo-phalangeal  synovial  mem- 
brane continued  downwards  as  1'  the  phalangeal  synovial  membrane  of  the 
thumb;  U.  the  internal  carpo-phalangeal  synovial  membrane  continued  down- 
wards as  2'  the  phalangeal  synovial  membranes  of  the  little  finger;  3,  4,  6,  the 
three  phalangeal  synovial  membranes  of  the  second,  third  and  fourth  fingers; 
6,  the  tendon  of  the  flexor  longus  pollicis;  7,  7,  the  tendons  of  the  flexor  pro- 
fundus digiiornm  ;  8,  median  nerve.  The  dotted  lines  represent  the  position 
of  the  anterior  annular  ligament. 


46         THE    SURGICAL    DISEASES    OF    CHILDR 


EN 


Fig.  0.— Diagram  showing  an  abnormal  arrangement  of  the  sheaths  of  the 
flexor  tendons  in  the  forearm  (from  Testut's  Anatomis).  The  references  are 
the  same  as  in  the  preceding  figure.  The  two  carpo-phalangeal  synovial 
sheaihs  have  coalesced  at  the  wrist. 

The  whitlow  caused  by  osteomyelitis  is  attended  by  much 
throbbing  pain  in  the  terminal  phalanx,  with  great  consti- 
tutional disturbance.  Pus  is  quickly  formed,  and  slowly 
makes  its  way  to  the  surface  unless  it  is  let  out  by  a 
timely  incision.  The  phalanx  dies  as  a  whole,  but  the 
tendon   sheath  is  not  as  a  rule  involved.       Sinuses  are 


NON-TUBERCULOUS    INFECTIVE    DISEASES        47 


Fio.  7. — Diagram  showing  another  abnormal  arrangement  of  the  sheaths  of 
the  flexor  tendons  in  the  forearm  (from  Testut's  Anatomie).  The  references 
are  the  same  as  in  fig.  5.  There  is  a  separate  synovial  sheath  in  this  form  for 
the  carpal  portion  of  the  long  flexor  of  the  index  finger  7'.  The  phalangeal 
portion  of  the  sheath,  however,  3',  remains  distinct. 


formed  in  cases  which  have  been  left  untreated,  and 
through  these  sinuses  the  necrosed  bone  may  readily  be 
removed. 

The  inflammation,  in  cases  of  thecal  abscess,  runs  a  very 
acute  and  severe  course.  It  may  lead  to  much  constitu- 
tional disturbance,  and   it  may  terminate  in  sloughing  of 


48         THE    SURGICAL    DISEASES    OF    CHILDREN 

the  tendons  affected.  The  diagrams  (figs.  5,  6  and  7)  copied 
from  Testut's  Anatomie  show  the  usual  and  the  two  un- 
usual forms  of  the  arrangement  of  these  important  sheaths 
in  the  hand  and  the  forearm.  When  they  are  inflamed 
the  abscess  is  likely  to  extend  through  the  hand,  especially 
if  the  thumb  or  little  finger  is  involved,  as  in  these  digits 
the  synovial  sheaths  are  in  direct  connection  with  the 
synovial  membrane  beneath  the  annular  ligament  at  the 
wrist.  Dr.  von  Rosthorn,  however,  has  shown  that  in 
new-born  children  each  of  the  fingers  possesses  a  separate 
phalangeal  synovial  sheath  which  does  not  communicate 
with  the  carpal  sac.  In  early  childhood  the  tendon  sheaths 
of  the  thumb  and  little  finger  gradually  extend  backwards 
until  they  coalesce  with  the  carpal  sheaths  to  form  the 
adult  condition  represented  in  fig.  5. 

Treatment. — Whitlows  are  always  evidence  of  greatly 
impaired  health,  and  when  they  are  recurrent,  as  is  fre- 
quently the  case  in  children,  I  think  that  they  imply  bad 
hygienic  surroundings,  or  that  they  indicate  a  strumoixs 
condition  which  is  especially  liable  to  pass  on  into  tubercle 
if  the  necessary  bacillus  is  forthcoming.  The  general 
health  should  therefore  be  attended  to  in  every  case,  and 
the  defective  hygienic  surroundings  should  be  remedied. 

Quinine  should  be  given  for  a  day  or  two,  and  the  child 
should  then  be  placed  upon  a  course  of  carbonate  of  iron  in 
some  agreeable  form. 

The  simplest  cases  may  be  treated  by  compresses  of 
absorbent  wool  soaked  in  a  1  in  20  solution  of  carbolic 
acid. 

The  fluid  in  a  subcutaneous  whitlow  should  be  let  out 
by  incising  the  cuticle,  which  is  an  absolutely  painless 
proceeding,  and  by  afterwards  fomenting  the  inflamed  part 
with  a  solution  of  boric  acid  containing  20  grains  to  the 
ounce. 


NON-TUBERCULOUS    INFECTIVE    DISEASES        49 

When  the  inflammation  is  produced  by  osteomyelitis, 
and  there  is  much  pain  and  swelling,  an  early  incision 
carried  along  either  side  of  the  affected  phalanx  through 
the  condensed  cellular  tissue,  until  the  point  of  the  knife 
touches  the  bone,  relieves  the  pain,  and  at  the  same  time 
renders  necrosis  less  likely  to  occur.  So  long  as  the  in- 
flammation persists,  the  affected  hand  should  be  soaked 
for  an  hour  or  more  once  or  twice  a  day  in  an  arm-bath  or 
basin  containing  a  solution  of  corrosive  sublimate  of  the 
strength  of  1  in  2000  at  a  temperature  of  100°  F.  The 
hand  must  be  dressed  antiseptically  in  the  intervals,  and 
suspended  in  a  sling.  The  epiphyseal  end  of  the  phalanx 
often  escapes  in  these  cases,  so  that  a  shortened  but  useful 
finger  results. 

Thecal  abscess  I  have  only  seen  in  boys  after  twelve 
years  old.  Mr.  Morrant  Baker0  points  out  that  a  thecal 
abscess  can  be  distinguished  from  the  whitlow  due  to 
osteomyelitis  by  the  early  impairment  of  voluntary  move- 
ment in  the  distal  phalanx.  He  recommends  that,  in 
order  to  estimate  the  movement  of  the  tendon  within  its 
sheath,  the  second  phalanx  of  the  finger  should  first  be 
fixed  by  the  surgeon,  who  places  his  thumb  on  the  front 
of  the  second  phalanx  and  the  end  of  one  of  his  fingers  of 
the  same  hand  on  the  back  of  the  first  phalanx.  The 
patient  is  now  told  to  bend  his  finger,  and  the  surgeon 
will  then  be  able  to  recognise,  both  by  sight  and  by  touch, 
the  range  of  movement,  if  any,  still  possessed  by  the 
tendon.  If  the  terminal  phalanx  remains  motionless,  the 
presumption  is  that  by  some  means  the  profundus  tendon 
is  tethered.  It  often  happens,  on  the  other  hand,  that 
the  patient  can  bend  the  tip  of  this  finger  under  these 
conditions,  even  when  the  finger  has  been  long  and  exten- 
sively inflamed  ;  and  when  this  happens,  we  are  to  give 
a  favourable  prognosis,  for    we    are   taught  thereby  that 

E 


50        THE    SURGICAL    DISEASES    OF    CHILDREN 

the  inflammation  has  been  in  the  deeper  tissues  lying 
beneath  the  tendon  sheath.  A  stiff  finger,  however,  often 
follows  npon  this  form  of  whitlow. 

The  Treatment  consists  in  making  a  small  incision 
into  the  sheath  of  the  tendon  opposite  the  head  of  the 
metacarpal  bone,  for  this  is  the  lowest  point  reached  by 
the  synovial  membrane,  except  in  the  thumb  and  little 
finger. 

When  the  inflammation  extends  up  the  arm,  along  the 
synovial  sheaths  upon  the  inner  and  outer  side,  the  whole 
hand  becomes  acutely  inflamed,  and  the  swelling  and  puffi- 
ness  are  especially  marked  upon  its  back.  Unless  very 
active  measures  are  taken,  abscesses  form  and  burrow 
amongst  the  tendons  of  the  forearm,  and  the  patient  goes 
in  serious  danger  of  his  life. 

Free  incisions  must  be  made  in  these  cases  into  the 
palm  of  the  hand,  along  the  metacarpal  bones  anterior  to 
the  superficial  arch.  The  scalpel  must  only  be  used  to 
divide  the  skin  and  fascia,  the  deeper  tissues  being  sepa- 
rated with  a  director  until  the  abscess  is  laid  open.  A 
counter-opening  must  also  be  made  above  the  annular 
ligament,  between  the  tendons  of  the  flexor  carpi  radialis 
and  the  palmaris  longus,  and  a  drainage-tube  should  be 
passed  under  the  annular  ligament  between  the  two  open- 
ings. The  hand  and  arm,  as  in  the  previous  forms,  should 
be  kept  for  two  or  three  hours  a  day  in  an  arm-bath  con- 
taining a  solution  of  1  in  1000  perchloride  of  mercury,  at  a 
temperature  of  100°  ¥n  antiseptic  dressings  being  applied 
between  the  immersions.  Stimulants,  quinine,  and  good 
food  are  imperatively  necessary.  Patient  and  prolonged 
attempts  at  passive  movement  must  afterwards  be  carried 
out. 


CHAPTER  IV 
SUEGICAL   TUBERCULOSIS 

etiology. — Tuberculous  disease  occurs  so  frequently 
and  is  so  fatal  in  childhood,  that  it  has  been  estimated 
that  it  kills  one-third  of  the  children  who  annually  die  in 
hospitals.  Tubercle  in  adults  is  often  localised,  and  is  very 
frequently  pulmonary  ;  in  children  it  is  much  more  often 
generalised.  My  friend,  Dr.  Walter  Carr,  indeed  finds, 
as  a  result  of  extended  observations  in  the  post-mortem 
room  attached  to  the  Victoria  Hospital  for  Children,  that 
the  primary  focus  of  tubercle  occurred  in  the  lymphatic 
glands  in  72-5  per  cent,  of  cases  in  which  the  children  died 
of  this  disease,  and  of  these  no  less  than  65-8  per  cent, 
commenced  in  the  glands  of  the  thorax  or  abdomen.  He 
points  out,  however,  that  these  statistics  do  not  fairly 
represent  the  cases  of  tubercle  starting  in  joints  and  bone, 
for  such  cases  do  not  usually  die  in  hospitals.  The  bacilli 
doubtless  gain  access  by  small  local  lesions  directly  to  the 
lymphatics,  and  so  to  the  gland,  the  organisms  being 
originally  obtained  either  from  inhalation  or  from  the 
ingestion  of  contaminated  milk,  as  Dr.  Woodhead  has 
suggested.  When  once  they  have  obtained  a  local  habi- 
tation, they  readily  spread  through  the  lymphatic  system 
in  persons  who  present  them  with  a  congenial  soil.  The 
varying  receptive  power  offered  by  different  persons  is 
no  doubt  always  due  to  heredity,  but  the  tendency  can 
be  diminished  by  hygienic  means,  even  in  the  most  sus- 
ceptible. 

51 


52         THE    SURGICAL    DISEASES    OK    CHILDREN 

Pathology. — The  tubercle  bacillus,  by  the  irritation  it 
produces,  gives  rise  to  an  aggregation  of  leucocytes  ;  which, 
undergoing  slight  modifications,  are  known  as  miliary 
tubercles.  If  tubercle  bacilli,  and  tubercle  bacilli  only, 
are  present,  the  cells  grow  and  fuse,  finally  undergoing 
changes  in  the  direction  of  the  formation  of  fibrous  tissue. 
If,  on  the  other  hand,  the  ordinary  septic  bacilli  are  mixed 
with  the  tubercle  bacilli,  as  most  often  happens,  suppura- 
tion takes  place,  and  the  various  forms  of  tuberculous 
abscess  result.  It  is,  therefore,  of  the  utmost  importance 
that  all  wounds  in  connection  with  tuberculous  tissues 
be  kept  thoroughly  free  from  contamination  with  septic 
micro-organisms,  for  only  by  such  care  can  the  surgeon 
benefit  the  patient  upon  whom  he  operates.  Drainage- 
tubes  are  therefore  inadmissible,  except  under  special 
circumstances. 

Tuberculous  disease,  so  far  as  it  is  interesting  to  the 
surgeon,  affects  the  lymphatic  glands,  the  bones,  the 
joints,  and  bursse,  the  pleura,  the  peritoneum,  the  kidney, 
the  testis  and  the  skin.  Tuberculous  disease  of  the  brain, 
leading  to  the  formation  of  caseating  masses  or  to  a  sub- 
acute inflammation  of  its  meninges,  is  of  more  doubtful 
interest  to  him ;  as,  although  operations  have  been  per- 
formed for  the  relief  of  cerebral  tuberculosis,  they  have  not 
yet  been  attended  with  sufficient  success  to  warrant  any 
recommendation  of  them  for  general  use. 

Disease  of  the  lymphatic  glands  is  one  of  the  most 
frequent  of  the  primary  manifestations  of  tubercle.  No 
surgical  measures  are  of  service  for  the  relief  of  the  bron- 
chial and  mesenteric  glands  which,  as  Dr.  Carr's  statistics 
show,  are  most  commonly  affected,  for  they  are  beyond 
the  reach  of  operative  treatment,  but  much  can  be  done 
for  the  cure  of  those  glands  which  are  more  superficially 
placed. 


SURGICAL    TUBERCULOSIS  53 


TUBERCULOUS   LYMPHADENITIS. 

Varieties. — Tuberculous  infection  in  the  lymphatic 
glands  manifests  itself  as  it  does  in  other  parts  in  many 
ways.  Sometimes  there  is  a  simple  hyperplasia  of  the 
glandular  substance,  which  does  not  necessarily  involve 
the  capsule,  so  that  the  individual  glands  remain  separate 
and  distinct  ;  in  other  cases  they  are  matted  together,  and 
are  embedded  in  such  dense  fibrous  tissue  that  it  is  very 
difficult  to  remove  them  ;  whilst  in  other  cases,  again,  they 
suppurate  and  form  either  a  diffuse  abscess  or  a  localised 
bag  of  pus.  The  tuberculous  infection  is  often  limited  to 
the  glands,  when  it  is  frequently  the  mildest  form  in 
which  the  patient  can  have  the  disease — no  doubt,  because 
the  gland  tissue  has  the  power  of  destroying  the  infective 
material — -in  other  cases  the  tuberculous  adenitis  is  secon- 
dary to,  or  is  a  part  of,  a  generalised  tuberculosis.  Chil- 
dren under  ten  years  of  age  are  especially  liable  to  this 
form  of  tuberculous  disease,  and  in  its  primary  form  it  is 
more  often  seen  in  the  glands  of  the  neck  than  in  other 
parts. 

Prognosis. — The    prognosis    as    regards   life    and   dis- 
semination is  good  in  the  case  of  glands   situated   within 
the  reach  of  surgery,  but  local  infection  of  the  skin  often, 
occurs,  leading  to  unsightly  scars. 

Treatment. — The  treatment  of  tuberculous  glands  is 
either  palliative  or  operative.  It  should  be  remembered 
that  enlarged  glands  in  the  necks  of  children  are  not  always 
tuberculous,  for  they  are  often  associated  with  local  irri- 
tation. The  removal  of  lice,  eczematous  inflammations, 
carious  teeth,  mastoid  abscesses,  chronic  otitis  media,  and 
other  local  causes,  will  generally  lead  to  a  reduction  in 
the  size  of  the  affected  glands,  and  often  to   their  com- 


54         THE    SURGICAL    DISEASES    OF    CHILDREN 

plete  recovery.  Local  remedies  should  also  be  tried  in 
every  case.  The  judicious  application  of  iodine,  or  of  an 
ointment  containing  mercury  or  potassium  iodide,  with 
the  administration  of  one-drachm  doses  of  cod-liver  oil 
directly  after  food,  and  a  quarter  of  a  grain  of  grey  pow- 
der before  each  meal,  will  be  found  most  serviceable.  The 
patient  should,  if  possible,  be  sent  to  Margate  or  to  Broad- 
stairs  for  a  thorough  course  of  fresh  air. 

Operative  means  must  be  adopted  when  these  measures 
have  failed,  or  when,  as  often  happens,  the  child  is  brought 
at  too  late  a  period  for  them  to  be  tried.  Few  departments 
in  surgery  have  undergone  so  rapid  and  radical  a  change 
as  that  appertaining  to  the  removal  of  enlarged  tuberculous 
glands.  The  palliative  method  was  alone  employed  until 
1885,  when  Dr.  Clifford  Allbutt  and  Mr.  Pridgin  Teale, 
who  were  then  colleagues  at  the  Leeds  General  Infirmary, 
pointed  out  that  the  proper  treatment  lay  in  the  complete 
extirpation  of  the  glands  as  soon  as  it  was  clear  that  con- 
stitutional measures  were  unavailing  to  prevent  caseation, 
and  that  in  no  case  should  they  be  allowed  to  suppurate. 
Their  practice  and  advice  has  been  so  largely  followed,  that 
the  early  removal  of  tuberculous  glands  is  now  the  rule 
amongst  all  surgeons ;  the  only  contra-indications  being 
the  extreme  weakness  of  the  patient,  or  the  fact  that  the 
enlargement  is  part  of  a  general  tuberculosis. 

The  glands  most  frequently  requiring  removal  are  those 
occurring  in  the  neck,  beneath  and  along  the  anterior 
border  of  the  sterno-mastoid  muscle ;  the  glands  in  the 
anterior  fold  of  the  axilla,  and  the  superficial  and  deep 
glands  in  the  groin. 

The  indications  for  the  removal  of  tuberculous  glands 
are  their  size  and  their  condition. 

When  they  are  so  large  as  to  cause  disfigurement,  and 
when  there  is  the  slightest  indication  that  they  are  about 


SURGICAL    TUBERCULOSIS  55 

to  suppurate,  they  should  be  extirpated  without  delay. 
The  incision,  in  the  case  of  the  neck,  must  be  planned  so 
as  to  lead  to  the  smallest  amount  of  disfigurement,  and 
advantage  should  therefore  be  taken  of  natural  lines  and 
creases. 

Operation. — The  incision  should  be  linear,  and  of  suf- 
ficient size  to  enable  the  surgeon  to  see  clearly  what  he 
is  doing  ;  for  glands  are  nearly  always  more  deeply  situated 
than  they  appear  to  be  before  the  operation  is  commenced, 
and  serious  injury  may  be  done  to  the  arteries,  veins,  and 
nerves  of  the  neck,  unless  great  care  be  taken.  Lastly, 
every  effort  should  be  made  to  obtain  union  by  first  inten- 
tion. This  can  usually  be  effected  if  asepsis  be  ensured, 
and  care  be  taken  not  to  infect  the  skin  and  tissues  by 
opening  the  capsule  of  the  gland.  The  incision  should  be 
carried  on  until  the  capsule  is  reached,  the  knife  should 
then  be  laid  aside,  and  the  gland  freed  with  a  blunt - 
pointed  steel  director.  It  should  be  raised  between  the 
finger  and  thumb  as  soon  as  possible,  as  the  capsule  is 
liable  to  be  injured  and  the  wound  infected  if  it  be  seized 
with  a  vulsellum.  The  gland  can  often  be  pulled  out 
quite  easily,  but  in  many  cases  it  will  be  found  that  the 
capsule  has  become  adherent  to  the  surrounding  tissues, 
owing  to  the  chronic  inflammatory  processes  to  which  it- 
has  been  subjected.  It  is  then  absolutely  necessary  to  cut 
through  the  adhesions,  but  the  division  must  be  done  with 
the  greatest  care  and  deliberation  ;  for  even  large  nerves 
like  the  hypoglossal  and  the  spinal  accessory  may  be 
divided;  whilst  haemorrhage  from  injury  to  the  vessels  is 
not  infrequent.  All  bleeding  points  must  be  arrested  at 
once,  either  by  ligatures  or  by  the  use  of  pressure  force] »s, 
as  it  is  of  the  greatest  importance  that  the  wound  should 
be  kept  bloodless,  that  the  surgeon  may  see  what  he  is 
doing  at  every  stage  of  the  operation. 


56         THE    SURGICAL    DISEASES    OF    CHILDREN 

Several  glands  can  generally  be  removed  through  a 
single  well-planned  incision,  especially  if  there  be  a  skilful 
assistant  who  knows  how  to  make  each  in  turn  prominent. 
It  is,  however,  better  to  make  two  or  three  incisions 
rather  than  to  endeavour  to  dissect  blindly  or  extensively. 
The  sterno-mastoid  itself  sometimes  requires  division,  but 
this  is  not  a  serious  proceeding,  as  in  such  cases  it  has 
become  thin  and  atrophied  from  the  pressure  of  the  glands 
beneath  it.     Its  cut  ends  must  afterwards  be  sutured. 

The  greatest  gentleness  of  manipulation  is  required 
when  the  glands  are  caseating,  and  if  they  have  already 
suppurated,  but  with  care  they  may  be  moved  unrup- 
tured. It  too  often  happens  that  the  abscess  has  become 
diffuse  before  the  patient  is  seen  by  the  surgeon.  It  is 
then  necessary  to  lay  it  open,  remove  the  pus,  and  look 
carefully  for  the  remains,  or  for  the  capsule  of  the  gland. 
The  abscess  is  often  superficial,  whilst  the  gland  is  situated 
deeply  beneath  the  cervical  fascia.  The  sinus  leading  from 
the  abscess  to  the  gland  must  be  cautiously  enlarged,  and 
all  the  caseating  material  must  be  carefully  scraped  away 
with  a  sharp  spoon,  the  cavity  being  afterwards  swabbed 
out  with  a  solution  of  1  in  15  zinc  chloride,  or  with  a  solu- 
tion of  camphorated  naphthol,  and  afterwards  well  flushed 
with  a  boric  lotion.  Several  cases  of  poisoning  have  oc- 
curred after  the  use  of  camphorated  naphthol,  so  that  it  is 
better  not  to  leave  any  large  quantity  of  the  solution  in 
the  abscess  cavity.  The  same  treatment  must  be  adopted 
when  the  skin  is  undermined,  and  is  riddled  with  fistulous 
tracts.  It  is  often  advisable  in  these  cases  to  cut  away 
the  skin  clear  of  the  disease,  as  there  is  less  chance  of 
subsequent  infection  than  after  scraping.  The  skin- wound, 
in  either  case,  should  be  brought  together  with  point 
sutures  of  horsehair,  taking  care  that  the  edges  are  in 
exact  apposition.     It  is  then  dressed  with  sterile  or  cyanide 


SURGICAL    TUBERCULOSIS  5  7 

gauze,  and  usually  heals  by  first  intention,  if  care  be  taken 
to  keep  the  head  at  rest.  Many  surgeons  prefer  to  dust 
the  wound  with  iodoform,  boric  acid,  or  nitrate  of  bis- 
nmth ;  but  I  find  that  such  applications  are  unnecessary, 
as  the  repair  takes  place  equally  well  without  them.  The 
sutures  should  be  removed  as  soon  as  possible,  and  usually 
on  the  third  or  fourth  day,  when,  if  there  is  no  discharge, 
the  dressing  is  changed  for  a  layer  of  gauze,  kept  in  place 
by  collodion. 

Tuberculosis  of  the  various  Mucous  Membranes. 

This  form  of  tuberculosis  is  rather  frequent  in  children. 
The  tubercle  appears  either  in  the  form  of  circular  ulcers, 
each  with  a  well-defined  outline,  or  as  masses  of  granulation 
tissue.  They  may  be  seen  in  the  septum  nasi,  in  the  mouth, 
on  the  tonsils,  and  in  the  pharynx.  The  local  manifestation 
should  always  be  removed  early  and  completely,  unless  it 
forms  part  of  a  general  tuberculosis  ;  or  unless  it  be  situated 
in  a  part  like  the  pharynx,  where  an  operation  can  only  be 
palliative,  and  for  such  a  place  the  electro-cautery  may  be 
employed.     (See  also  chap,  xiii.) 

Tuberculous  Disease  of  the  Tendon  Sheaths. 

This  is  fairly  common  in  childhood.  It  may  begin  in  the 
sheaths  themselves,  or  it  may  be  secondary  to  bone  or  joint 
lesions.  The  inflammatory  process  either  gives  rise  to  the 
formation  of  nvnch  granulation  tissue,  or  it  may  in  rarer 
cases  produce  a  cystic  distension  of  the  tendon  sheaths. 
The  extensors  of  the  fingers  are  more  often  affected  than 
the  flexors. 

Prognosis. — The  prognosis  is  good  so  long  as  suppura- 
tion does  not  take  place  ;  though  the  secondary  forms  are 
unsatisfactory,  owing  to  the  unhealthy  state  of  the  sur- 
rounding parts. 


58         THE    SURGICAL    DISEASES    OF    CHILDREN 

Treatment. — A  clean  sweep  should  be  made  of  the 
whole  of  the  affected  tissue  by  careful  scraping,  under  the 
strictest  antiseptic  precautions. 

Primary  Tuberculous  Infection  of  the  Skin. 
The  skin  is  sometimes  the  primary  seat  of  tubercle,  and 
of  this  a  good  example  recently  came  under  my  notice. 
A  healthy  student,  who  had  no  tuberculous  relations, 
scratched  his  knuckles  whilst  making  a  post-mortem  ex- 
amination of  a  tuberculous  heifer,  and  the  sore  place  never 
healed  properly.-  Four  months  later,  when  he  applied  to 
me  for  advice,  there  were  three  small  circular  patches, 
each  surrounded  with  an  inflamed  zone,  lying  immediately 
over  the  right  extensor  indicis  tendon.  The  centre  of 
each  patch  was  a  scab.  The  growths  were  removed, 
and  were  subjected  to  microscopical  examination.  They 
consisted  of  granulation  tissue,  containing  giant  cells, 
but  no  tubercle  bacilli  were  detected.  A  year  later  the 
patient  was  in  perfect  health.  Such  cases  are  not  very 
uncommon,  and  when  there  is  reason  to  suspect  their 
tuberculous  character,  excision  is  the  best  mode  of  treat- 
ment. In  most  cases,  tuberculous  inflammation  of  the  skin 
is  secondary,,  and  the  result  of  direct  extension  from  other 
and  deeper  tissues,  as  from  a  case  of  tuberculous  lympha- 
denitis. The  sores  produced  in  such  cases  are  puckered, 
blue,  and  often  very  unsightly.  They  often  show  a  great 
tendency  to  break  down. 

LUPUS, 
etiology. — Lupus,  is  defined  by  Professor  Leloir  as  a 
slightly  virulent  form  of  tuberculosis  of  the  integuments. 
The  elementary  lesion  is.  a  tubercle,  reddish  brown  in 
colour,  soft  in  consistence,  developing  slowly,  and  destroy- 
ing the  tissues  either  by  interstitial  absorption,  by  ulcera- 
tion, or  by  sclerosis. 


SURGICAL    TUBERCULOSIS  59 

Pathology. — Lupus  may  attack  any  part  of  the  skin  or 
the  mucous  membrane  adjacent  to  it.  It  generally  begins 
in  infancy,  and  may  produce  a  partial  or  general  infection 
of  the  S3rstem.  The  primary  lesion  is  either  nodular  or 
diffuse.  Its  tuberculous  character  has  been  demonstrated 
by  the  production  of  general  tuberculosis  in  animals  who 
have  been  inoculated  with  lupus ;  and  there  appears 
reason  to  suppose  that  lupus  in  a  child  is  often  the  result 
of  direct  inoculation  from  an  external  source,  though  it 
may  sometimes  be  the  result  of  auto-infection.  It  is 
characterised  microscopically  by  the  large  number  of  giant 
cells  contained  in  the  growth.  The  cells  caseate  rather 
less  rapidly  than  in  an  ordinary  tuberculous  nodule,  and 
the  infiltrated  area  is  somewhat  more  vascular.  The 
tubercle  bacilli  are  very  few  in  number.. 

Course. — The  affection  may  continue  throughout  life, 
and  often  causes  lasting  deformity.  It  attacks,  by  pre- 
ference, the  nose  and  cheeks,  and  it  often  begins  sym- 
metrically upon  either  side  of  the  face,  the  two  patches 
afterwards  extending  and  becoming  connected  across  the 
nose.  It  may  also  affect  the  pinna  of  the  ear,  and  more 
rarely  the  skin  in  the  neighbourhood  of  the  joints,  whose 
movements  it  may  seriously  hamper  by  ulceration  and 
cicatrisation  of  the  skin.  It  hardly  ever  attacks  the 
genital  organs  either  in  girls  or  boys.  I  have  seen  it 
spread  from  the  upper  lip  to  the  gums  and  tongue, 
causing  extensive  ulceration. 

Diagnosis. — It  has  to  be  distinguished  from  some  forms 
of  eczema  and  from  cutaneous  syphilides.  Its  chronic 
course  will  distinguish  it  from  either  unless,  as  often 
happens  in  hospital  practice,  syphilis  and  tubercle  are 
coexistent. 

Treatment. — Lupus,  at  any  rate,  in  children  is  no 
longer  the   bugbear  that  it  was   to    the   older   surgeons. 


60        THE    SURGICAL    DISEASES    OF    CHILDREN 

Scraping  and  skin-grafting  have  enabled  us  to  do  some- 
thing towards  its  cure,  though  there  are  frequent  relapses, 
and  scarring  is  unavoidable.  The  treatment  I  usually 
adopt  is  one  which  was,  I  believe,  originally  introduced  by 
Mr.  Arbuthnot  Lane,  and  it  often  yields  excellent  results. 
The  patch  of  lupus  and  the  surrounding  skin  is -disinfected 
as  far  as  possible  overnight,  and  is  protected  with  a  gauze 
dressing.  An  anaesthetic  is  given  on  the  morrow,  and  the 
whole  of  the  diseased  area  is  scraped  away  with  a  sharp 
spoon,  especial  care  being  taken  to  destroy  every  part  of 
the  sinuous  edge  and  all  outlying  patches.  The  diseased 
area  is  readily  recognised  by  the  readiness  with  which  it 
breaks  down  under  the  scoop,  whilst  the  healthy  tissue 
grates  and  shows  no  tendency  to  be  removed.  The  bleed- 
ing is  stopped  by  pressure,  and  precipitated  sulphur 
is  sprinkled  over  the  whole  of  the  raw  surface,  which 
is  then  dressed  with  dry  cyanide  gauze.  The  sulphur 
produces  a  superficial  and  very  complete  slough,  which 
separates  on  the  fourth  or  fifth  day,  leaving  a  healthy 
granulating  surface.  It  should  then  be  dressed  daily 
with  boracic  ointment,  the  wound  being  bathed  with  a 
solution  of  boric  acid. 

Skin-grafting  by  a  modification  of  Thiersch's  method 
(q.  v.)  is  adopted  as  soon  as  the  wound  is  clean ;  for 
routine  purposes,  this  is  a  week  after  the  scraping.  The 
grafts  are  usually  taken  from  the  anterior  aspect  of  the 
thigh.  The  part  is  disinfected  and  an  antiseptic  dressing 
is  applied  on  the  day  preceding  the  operation.  The 
patient  is  anaesthetised,  and  the  wound,  as  well  as  the 
skin  of  the  thigh,  is  washed  with  a  solution  of  perchloride 
of  mercury,  1  in  2000.  The  skin-grafts  are  shaved  off  with 
a  broad  razor,  moistened  with  a  0-6  per  cent,  solution  of 
common  salt.  The  grafts  should  be  as  long  and  broad  as 
possible,  and  they  should  be  sufficiently  numerous  to  cover 


SURGICAL    TUBERCULOSIS  6  I 

the  whole  of  the  wound.  They  are  best  obtained  by  flexing 
the  leg  and  thigh,  and  by  then  stretching  the  skin  with 
the  thumb  and  forefinger  of  the  left  hand.  The  razor  is 
made  to  cut  through  the  tops  of  the  cutaneous  papillae, 
so  that  a  slight  oozing  of  blood  marks  its  course.  The 
mistakes  most  frequently  made  are  not  to  cut  with  suf- 
ficient boldness,  so  that  the  grafts  are  too  small  and  too 
thin,  for  they  will  then  only  consist  of  squamous  cells  ; 
on  the  other  hand,  an  operator  whose  hand  is  heavy  or 
whose  sight  is  bad,  cuts  too  deeply,  so  that  his  grafts 
have  an  under  surface  of  fibrous  tissue  or  fat,  often  covered 
with  a  layer  of  blood,  which  clots.  Grafts  which  are 
properly  cut  have  a  slimy  feel  and  are  pale  in  colour. 
They  have  a  great  tendency  to  curl  up,  so  that  it  is  better 
to  float  them  from  the  razor  straight  on  to  the  wound. 
They  should  be  fitted  together  by  means  of  a  probe,  in  such 
a  way  that  their  edges  slightly  overlap.  A  piece  of  green 
protective,  moistened  with  a  sterilised  salt  solution,  is  then 
placed  over  the  wound,  gauze  dressings  are  applied,  and 
the  part  is  not  dressed  for  a  week.  It  will  usually  be 
found  that  most  of  the  grafts  have  taken,  whilst  the  parts 
which  remain  uncovered  are  rapidly  healed  by  the  sur- 
rounding epithelium.  The  thigh  is  dressed  with  antiseptic 
dressings  in  the  ordinary  manner. 

Many  surgeons  have  followed  the  plan  introduced  by 
Mr.  AVatson  Cheyne,  of  dissecting  out  lupus  patches, 
making  an  incision  through  the  healthy  skin,  and  remov- 
ing the  subcutaneous  fat  over  the  infected  area.  The 
bleeding  is  staunched  and  the  wound  is  immediately 
covered  with  skin-grafts. 


CHAPTER  V 

TUBERCULOUS  DISEASE   OF  BONE 

^Etiology. — Tuberculous  osteitis7  is  one  of  the  commonest 
bone  diseases  seen  in  children.  It  affects  all  the  bones, 
long  and  short,  cylindrical  and  flat,  cartilaginous  and 
membranous.  It  is  frequently  a  mixed  infection,  but  in 
some  cases,  and  especially  in  the  phalanges  and  meta- 
carpal bones,  the  inflammation  may  be  due  to  the  tubercle 
bacillus  alone,  without  any  intermixture  of  septic  organ- 
isms. Tuberculous  osteitis  seems  to  occur  spontaneously 
in  many  cases,  for  it  is  often  impossible  to  obtain  a  history 
of  any  exciting  cause,  but  it  usually  follows  an  injury. 

Pathology. — The  tuberculous  deposit  is  found  typically 
in  the  cancellous  tissue,  but  it  may  occur  deeply  in  the 
substance  of  the  compact  bone,  beneath  the  cartilages  or 
sub-periosteally.  The  labours  of  Lannelongue,  Oilier,  and 
other  members  of  the  great  French  school  of  scientific 
surgery,  have  proved  that  tuberculous  disease  of  bone 
very  often  begins  in  the  long  bones  as  a  localised  deposit 
in  the  neighbourhood  of  the  epiphyseal  line. 

Anatomical  Characters. — The  deposit  of  tubercle,  as  it 
is  seen  in  its  earliest  condition,  consists  of  minute  nodules 
lying  in  the  cancellous  tissue.  These  nodules  rapidly 
undergo  caseation,  and  coalesce,  in  some  cases  leading  to 
very  little  damage,  but  usually  causing  absorption  of  the 
bone,  by  setting  up  a  process  of  rarefying  osteitis.     The 

62 


TUBERCULOUS    DISEASE    OF    BONE  63 

caseated  products  sometimes  undergo  absorption,  they  may 
become  converted  into  fat,  but  much  more  frequently  sup- 
puration occurs,  and  the  bone  becomes  carious.  In  the 
long  bones,  the  process  of  suppuration  may  be  very  chronic, 
and  does  not  give  rise  to  many  symptoms,  so  that  a 
chronic  abscess  of  bone  may  result ;  in  other  cases  the 
suppuration  may  be  much  more  acute,  and  may  lead  to  the 
destruction  of  a  fragment  of  bone  which  then  lies  in  an 
abscess,  the  condition  being  known  as  '"  caries  necrotica." 
Necrosis,  however,  is  not  a  common  result  of  tuberculous 
osteitis  in  children ;  and  it  only  occurs  in  cases  of  mixed 
infection.  The  disease  ends  either  in  destruction  of  the 
bone,  and  its  replacement  by  scar  tissue  of  a  fibrous  type, 
or  in  condensation  of  the  bone,  owing  to  the  continued 
irritation  to  which  it  has  been  subjected.  This  sclerosis 
is  often  so  complete  that  such  a  bone  as  the  tibia  may  con- 
sist entirely  of  compact  tissue ;  in  such  cases  it  is  often 
longer  than  its  fellow  and  much  more  curved. 

Symptoms  and  Course.— The  symptoms  of  tubercu- 
lous inflammation  of  bone  vary  greatly.  It  occurs  in  the 
simplest  form,  in  tuberculous  inflammation  of  the  fingers 
or  toes  (p.  70)  and  in  the  bones  of  the  carpus  and  tarsus. 
The  pain  in  these  cases  is  only  slight  and  of  a  pricking 
character,  worse  at  night,  and  when  the  part  is  subjected 
to  pressure  or  when  it  is  moved.  The  bone  is  often 
expanded,  and  its  interior  is  converted  into  a  mass  of 
softened  tissue,  which  leaves  a  mere  shell  of  compact 
tissue  when  it  has  been  removed.  The  skin,  at  first 
unaffected,  afterwards  may  become  involved  in  a  true 
tuberculous  inflammation.  These  symptoms  subside  in 
the  simplest  cases,  and  a  slow  but  spontaneous  cure  may 
result.  A  mixed  infection,  however,  is  much  more  fre- 
quent :  an  abscess  forms  whicli  opens  externally,  leaving 
a  fungating  sinus,  along  which  the  disintegrated  portions 


64         THE    SURGICAL    DISEASES    OF    CHILDREN 

of  bone  pass  for  long  periods  of  time.  The  sinuses  may 
eventually  close,  and  a  depressed  and  puckered  scar  re- 
mains to  show  where  they  were.  In  the  worst  forms, 
sequestra  may  be  produced,  or  many  bones  may  become 
involved  in  the  carious  process.  The  skin  and  surround- 
ing tissues  become  widely  involved,  the  joints  are  impli- 
cated ;  and  unless  amputation  be  performed,  there  is  dan- 
ger of  death  from  lardaceous  disease ;  or  if  the  bone  lesion 
be  part  of  a  general  tuberculosis,  from  cerebral  meningitis. 

Diagnosis. — The  diagnosis  is  usually  easy,  but  where 
there  is  a  deposit  of  tubercle  deeply  seated  in  one  of  the 
long  bones  it  is  extremely  difficult  to  recognise,  and  it  is 
then  likely  to  be  mistaken  for  chronic  osteomyelitis,  or  for 
a  sarcomatous  growth  within  the  bone.  Verneuil  says 
that  tuberculous  osteitis  can  be  distinguished  from  a 
sarcoma  by  the  greater  pain  attending  the  malignant 
growth,  and  by  the  fact  that  the  temperature  of  the 
affected  limb  is  two  or  three  degrees  higher  than  its 
fellow ;  whilst  in  tuberculous  osteitis  such  a  difference 
in  the  heat  of  the  two  limbs  does  not  occur. 

The  differential  diagnosis  has  to  be  made  between  a  new 
growth  and  inflammatory  swelling  of  bone,  and  this  can 
best  be  done,  as  Mr.  Howard  Marsh  has  very  ably  pointed 
out,  by  paying  attention  to  the  following  points.  Osteitis 
is  more  common  in  children  than  a  new  growth.  An  injury 
is  more  likely  to  lead  to  an  inflammation  of  bone  than  to  a 
sarcoma.  A  uniform  swelling  of  the  bone  is  more  likely 
to  be  inflammatory  than  a  lobed,  nodular  or  irregular  one. 
Sarcomata  in  children  are  often  very  soft,  whilst  the 
inflammatory  swellings  are  densely  hard.  The  rate  of 
growth  affords  very  little  information,  for  in  both  forms 
of  swelling  it  may  be  slow  or  rapid.  The  condition  of  the 
skin  overlying  the  tumour  is  not  a  much  more  trustworthy 
guide  than  the  rate  of  the  growth,  whilst  the  body  tern- 


TUBERCULOUS    DISEASE    OF    BONE  65 

perature  in  inflammatory  conditions  is  generally  subject  to 
greater  variations  than  in  sarcoma.  The  symptoms,  how- 
ever, are  often  so  similar  in  the  two  conditions  that  it  is 
impossible  to  make  an  accurate  diagnosis,  though  usually 
they  are  so  distinct  as  to  render  a  mistake  impossible. 

Prognosis. — No  general  rule  can  be  laid  down  in  re- 
gard to  the  prognosis,  for  so  much  depends  upon  the  posi- 
tion as  well  as  upon  the  extent  of  the  disease.  Each  case 
therefore  has  to  be  considered  upon  its  merits. 

Treatment. — The  first  treatment  to  be  adopted  in  every 
case  of  tuberculous  osteitis  consists  in  rest  of  the  affected 
part,  with  an  improvement  of  the  patient's  health  by 
sending  him  to  the  seaside,  and  preferably  to  some 
bracing  place,  as  well  as  by  the  administration  of  cod- 
liver  oil.  The  tubercle  bacillus  has  so  uncertain  a  tenure 
of  life  that  in  many  cases  the  disease  can  be  cured  by 
these  means.  Physiological  rest  is  best  secured  by  the 
application  of  a  plaster-of-Paris  splint  or  by  a  Thomas' 
splint. 

Operative  interference  is  called  for  when  the  local 
symptoms  do  not  speedily  subside  under  this  treatment  ; 
and  when  pyogenic,  as  well  as  tubercle  bacilli,  are  present, 
this  can  hardly  be  expected.  The  surgeon  then  endeavours 
to  remove  the  tuberculous  foci  as  completely  as  possible. 
An  Esmarch's  bandage  is  therefore  applied,  the  bone  is  ex- 
posed, all  the  unhealthy  tissue  is  scraped  away,  the  cavity 
is  treated  with  zinc  chloride,  washed,  and  an  endeavour 
is  made  to  obtain  union  by  first  intention.  I  used  to  fill 
the  cavities  with  iodoform,  camphorated  naphthol,  bismuth, 
boric  acid,  or  other  disinfectant ;  but  as  time  goes  on  I  find 
myself  less  inclined  to  use  any  antiseptic  in  these  cases, 
and  to  trust  entirely  to  aseptic  methods  when  the  disease 
has  once  been  removed  completely,  for  I  am  sure  that  the 
best  results  are  obtained  by  their  means.    When  there  has 

F 


66         THE    SURGICAL    DISEASES    OF    CHILDREN 

been  prolonged  suppuration,  however,  and  union  by  first 
intention  is  impossible,  the  ordinary  antiseptic  solutions 
must  be  employed.  Amputation  is  sometimes  necessary 
in  cases  of  tuberculous  osteitis  which  have  been  neglected. 
It  is  especially  useful  in  the  foot,  where  the  whole  of  the 
tarsal  bones  are  often  so  extensively  diseased  as  to  render 
it  the  only  available  method  of  treatment. 

TUBERCULOUS  DISEASE  OE  THE  LONG  BONES. 

(1)  Epiphyses. 

Tuberculous  disease  affects  either  the  epiphyses  or  the 
shafts  of  the  long  bones.     The  epiphyses  are  rather  more 
frequently  implicated,  and  the  disease  assumes  the  form 
of  an  osteomyelitis,  leading  either  to  f  ungation,  to  necrosis, 
or  to   infiltration  of  the  affected  tissues.     The  fungating 
form  often  leads  to  implication  of  the  joint,  and  is  described 
more  fully  at  page  98.     The  necrosing  variety  leads  to  the 
formation  of  an  abscess  in  the  head  of  the  bone,  which 
can  be  distinguished  from  that  due  to  septic  osteomyelitis 
by  the  fact  that  it  is  less  frequently  surrounded  by  a  layer 
of  dense  bone,  though  it  has  a  much  better  defined  pyogenic 
membrane.     The  sequestra  vary,  for  they  are  sometimes 
small  and  caseating,  sometimes  larger  and  wedge-shaped. 
These  cuneiform  masses  can  be  produced  artificially  by  in- 
jecting tuberculous  substances  into  the  nutrient  artery  of 
the  bone,  and  it  therefore  appears  as  if  they  had  an  embolic 
origin.     The  infiltrating  form  of  tuberculous  osteomyelitis 
is  the  least  common  and  the  most  unsatisfactory  to  treat, 
for   it   progresses   steadily,  and  is   often  associated   with 
extensive  suppuration. 

Course. — The  disease  runs  a  very  chronic  course,  and 
may  terminate  in  a  chronic  abscess  near  the  head  of  the 
bone,  which  may  remain  for  years,  and  may  then  open  to 


TUBERCULOUS    DISEASE    OF    BONE  6j 

the  exterior  or  into  the  joint ;  in  other  cases  rapid  funga- 
tion  may  take  place,  and  with  similar  results.  The 
surrounding  tissues  often  become  involved  in  the  tuber- 
culous process,  and  a  complicated  system  of  sinuses  is 
developed,  which  lasts  for  years  if  it  is  left  without 
treatment. 

Symptoms. — The  symptoms  are  generally  very  obscure 
when  the  tubercular  deposit  takes  place  deeply  in  the 
epiphyseal  line,  and  it  is  often  only  discovered  accidentally 
on  making  a  section  of  the  bone,  after  death,  or  after  it 
has  been  removed  for  some  other  reason.  It  is  more  easy 
to  recognise  when  it  occurs  in  the  superficial  than  when 
it  is  in  the  more  deeply  seated  bones,  and  more  easy  when 
it  suppurates  than  when  it  is  encysted.  The  symptoms 
upon  which  alone  any  reliance  can  be  placed  are  pain, 
swelling,  local  tenderness,  redness  when  the  skin  is  be- 
coming involved,  and  atrophy  of  the  muscles,  due  some 
think  to  disuse,  whilst  others  hold  that  it  is  a  result 
of  nervous  disturbances  in  the  affected  part  (see  also 
pp.  74  and  114). 

Prognosis. — The  prognosis  upon  the  whole  is  not  so 
serious  as  it  was  forty  years  ago,  when  constitutional 
measures  were  relied  upon  to  the  exclusion  of  all  other 
means  except  amputation.  The  disease  is  always  tedious 
and  often  dangerous,  but  with  care  and  repeated  atypical 
operations  good  results  are  often  obtained. 

Treatment. — The  general  treatment  consists  in  remov- 
ing the  cause,  if  possible,  by  improving  the  general  tone  of 
the  tissues,  and  so  enabling  them  to  destroy  the  bacillus ; 
if  this  is  not  feasible,  by  injecting  such  sclerosing  agents 
as  zinc  chloride  (p.  102)  to  convert  the  inflammatory  pro- 
ducts into  fibrous  tissue,  or  else  cutting  down  upon  the 
part  and  removing  the  products  of  tuberculous  action,  f<  r 
when  this  is  done  the  inflamed  tissues  are  often  found  to 


68         THE    SURGICAL    DISEASES    OF    CHILDREN 

be  capable  of  preventing  the  further  growth  of  the  tubercle 
bacillus.  It  is  essential,  however,  that  the  parts  should 
be  kept  strictly  aseptic.  In  tuberculous  infection  of  the 
epiphyses,  a  thorough  exploration  of  the  epiphyseal  line 
should  be  made  as  soon  as  there  is  evidence  that  the 
inflammatory  focus  has  suppurated,  for  there  is  great 
danger  lest  the  joint  become  involved  either  by  the  direct 
spread  of  inflammation  or  by  sympathy. 

(2)  Shafts. 

Tuberculous  osteitis  of  the  shafts  of  long  bones  is  either 
primary  or  secondary  when  it  results  from  extension  from 
the  epiphyseal  line,  and  this  is  the  more  common  form. 
The  inflammation  runs  the  same  course,  and  presents  the 
same  obscure  symptoms  in  its  earlier  stages  as  in  the 
similar  condition  of  the  epiphyses.  Necrosis,  however,  is 
somewhat  more  common,  and  in  some  cases  the  bones 
become  the  seat  of  a  remarkable  form  of  rarefying  osteitis, 
which  is  more  fully  described  at  page  70,  and  leads  to 
the  formation  of  a  condition  known  as  spina  ventosa. 
The  sequestrum  is  sometimes  situated  between  the  laminae 
of  the  compact  bone,  and  its  presence  is  attended  by  sup- 
puration. The  bone  then  slowly  enlarges  and  becomes 
painful,  and  the  condition  is  likely  to  be  mistaken  for  a 
sarcoma ;  in  other  cases  condensation  and  sclerosis  of  the 
entire  bone  may  take  place.  The  disease  is  more  often  an 
osteomyelitis  than  a  periostitis,  though  the  periosteum  is 
involved  in  the  later  stages.  The  general  treatment  is 
the  same  as  in  the  epiphyseal  infection. 

TUBERCULOUS  DISEASE  OF  THE  SHORT 
AND  OF  THE  FLAT  BONES. 

In  the  skull  tuberculous  disease  sometimes  affects  the 
frontal  and  parietal   bones,  though  the  mastoid  may  be 


TUBERCULOUS    DISEASE    OF    BONE  69 

implicated  secondarily  from  the  middle  ear  (q.v.).  An 
abscess  pointing  externally,  ornecros  is  of  the  whole  thick- 
ness of  the  bone,  may  be  the  first  sign  of  the  disease,  as  it  is 
not  usually  characterised  by  any  marked  symptoms.  The 
child  may  even  die  with  symptoms  of  cerebral  compression, 
when  the  tuberculous  inflammation  has  been  limited  to  the 
inner  table  of  the  skull,  without  any  suspicion  of  the  true 
cause  of  the  condition.  The  treatment,  when  the  disease 
is  recognised,  consists  in  opening  the  abscess,  scraping 
away  any  fungating  material,  and  causing  it  to  heal  as 
quickly  as  possible. 

The  superior  maxilla,  the  malar,  and  the  lower  jaw  are 
the  most  common  seats  of  tuberculous  disease  in  the  face. 
Caries  is  somewhat  more  common  in  these  bones  than 
necrosis,  and  the  treatment  consists  in  cutting  down  upon 
the  affected  part  and  clearing  away  the  softened  tissue 
with  a  sharp  spoon  and  a  rugine.  The  only  complication 
likely  to  occur  in  the  case  of  caries  of  the  superior  maxilla 
is  a  stillicidium  lachrymarum  from  interference  with  the 
nasal  duct. 

Tuberculous  disease  of  the  ribs,  according  to  Schmalfuss 
and  Fasbender,  in  children  under  fifteen  years  of  age 
forms  125  per  cent,  of  all  recorded  cases  of  caries  of  the 
ribs.  The  disease  is  either  primary  or  it  is  secondary 
to  an  empyema  of  tuberculous  origin,  but  in  either  case 
tuberculous  periostitis  is  more  common  than  a  lesion  of 
the  bone  itself.  A  chronic  abscess  is  the  great  sign 
of  the  disease.  It  should  be  opened,  and  the  diseased 
ribs  should  be  resected.  The  sternum  is  occasionally  the 
seat  of  tuberculous  caries,  leading  to  the  formation  of  an 
abscess  which  may  project  into  the  mediastinum  or  to 
sinuses  opening  externally. 

The  clavicle  and  the  scapula  are  sometimes  affected 
with  tubercle,  but  the  disease  in  these  bones  is  more  often 


JO        THE    SURGICAL    DISEASES    OF    CHILDREN 

connected  with  disease  of  the  shoulder  and  of  the  sterno- 
clavicular joints.  The  bones  of  the  carpus  and  tarsus  are 
frequently  the  seat  of  tuberculous  deposits,  but  they  are 
in  the  same  way  usually  associated  with  tuberculous 
disease  of  the  joints  of  which  they  respectively  form  a  part 
(pp.  Ill  and  137). 

TUBERCULOUS  DACTYLITIS. 

Inflammation  of  the  phalanges  of  the  fingers  and  toes, 
and  of  the  metacarpal  and  metatarsal  bones,  often  occurs 
as  a  form  of  simple  tuberculous  inflammation  in  children. 
It  usually  affects  children  during  the  second  and  third 
year,  biit  it  may  occur  at  any  time  between  the  first  and 
the  sixteenth  year.  The  metacarpus  is  more  often  affected 
than  the  neighbouring  phalanges,  the  metatarsus  more 
often  than  the  phalanges  of  the  toes. 

Pathology  and  Morbid  Anatomy. — The  disease  is 
essentially  a  tuberculous  osteomyelitis,  either  commencing 
in  the  bones  themselves,  or  less  frequently,  immediately 
beneath  the  periosteum.  The  affected  part  becomes  en- 
larged, and  the  bone  undergoes  a  process  of  rarefaction, 
which  may  either  terminate  in  resolution,  with  or  without 
deformity,  or  in  fungation  and  suppuration,  which  may 
lead  to  necrosis.  The  bone  is  often  so  thinned  and  ex- 
panded as  to  leave  only  a  perforated  skeleton,  thus  afford- 
ing the  most  perfect  examples  of  rarefaction. 

Symptoms. — The  patient  is  often  a  typically  tuberculous 
child,  and  the  enlargement  of  the  bone  comes  on  as  part  of 
a  general  process.  It  is  painless  and  uniform,  and  does 
not  attain  a  maximum  for  many  weeks.  The  skin  and  the 
overlying  tendons  are  at  first  free,  but  they  often  become 
involved.  The  movements  of  the  bone  are  impaired,  the 
skin  is  first  thin  and  then  yields,  so  that  a  depressed  sinus 


TUBERCULOUS    DISEASE    OF    BONE  7 1 

is  left  with  granulations  springing  from  it.  A  probe 
passed  along  the  sinus  reveals  softened  or,  in  rarer  cases, 
dead  bone. 

Diagnosis. — The  diagnosis  is  not  difficult,  for  the  only 
condition  for  which  it  is  likely  to  be  mistaken  is  enchon- 
droma,  syphilitic  dactylitis,  or  the  results  of  acute  septic 
osteomyelitis.  Enchondroma  is  harder,  has  no  tendency  to 
suppurate,  and  runs  a  more  chronic  course.  Syphilitic 
dactylitis  is  much  less  common  than  the  tuberculous  form, 
occurs  in  a  different  type  of  child,  is  amenable  to  anti- 
syphilitic  remedies,  and  is  periosteal  rather  than  endosteal 
in  origin.  Septic  osteomyelitis  runs  a  different  course  from 
the  commencement. 

Prognosis. — The  prognosis  is  good  as  regards  the  local 
indications,  but  it  is  bad  as  regards  the  general  health  of 
the  child,  since  it  usually  occurs  in  connection  with  other 
manifestations  of  tubercle. 

Treatment. — The  treatment,  as  is  usual  in  tuberculous 
disease  of  bones,  consists  essentially  in  rest.  The  affected 
part  is  put  upon  a  splint,  after  compression  has  been 
applied  by  means  of  strips  of  plaster,  whilst  the  health  of 
the  child  is  improved  as  far  as  possible.  When  these 
means  fail,  and  when  fistulas  have  formed,  the  limb  should 
be  rendered  bloodless,  and  the  sinuses  should  be  enlarged, 
so  that  the  parts  may  be  thoroughly  scraped.  Care  must 
be  taken  to  avoid  injuring  the  tendons  or  their  sheaths. 
The  cavity  is  then  dusted  with  iodoform,  and  is  dressed 
antiseptically.  The  disease  runs  so  chronic  a  course  that 
there  is  always  a  little  danger  of  leaving  it  alone  until 
the  mischief  is  too  far  advanced  to  enable  operative  mea- 
sures to  be  of  any  avail.  The  best  results  are  obtained 
by  operating  as  soon  as  it  is  clear  that  rest  is  useless. 


J  2         THE    SURGICAL    DISEASES    OF    CHILDREN 


POTT'S  DISEASE   OE   THE   SPINE. 

Pathology. — Pott's  disease  of  the  spine  occurs  at  any 
age,  and  in  both  sexes.  It  is  most  frequent  in  the  first 
decennium,  and  after  the  age  of  two  years.  It  is  due  to 
tuberculous  changes  in  the  bodies  of  the  vertebras,  the 
changes  usually  commencing  in  the  anterior  parts  of  the 
body  close  to  the  lines  of  the  epiphyses,  though  the 
posterior  portions  may  also  be  affected.  The  tuberculous 
inflammation  leads  to  rarefying  osteitis,  with  subsequent 
absorption  of  more  or  less  of  the  cancellous  tissue,  and 
the  eventual  fusion  of  those  parts  of  the  vertebral  column 
which  are  brought  into  apposition  by  the  curvature  neces- 
sarily ensuing  upon  the  disappearance  of  the  front  of  the 
column.  The  progress  of  the  disease  is  usually  slow,  often 
taking  years  to  run  its  course ;  caseation  may  then  take 
place  with  sclerosis.  If  the  infection  is  mixed,  or  if  the 
disease  runs  an  acute  course,  and  only  lasts  months  instead 
of  years,  necrosis  may  take  place  with  the  formation  of 
extensive  abscesses. 

etiology. — HofFa  states  that  the  tuberculous  osteitis 
usually  commences  at  that  part  of  the  spinal  column 
which  is  most  exposed,  where  movements  make  the 
greatest  demand  upon  it,  and  where  the  weight  of  the 
body  is  chiefly  incident.  It  is  therefore  most  common, 
he  says,  in  children  in  the  cervical  vertebras,  and  in  later 
life  in  the  lumbar  region ;  in  the  neck  the  upper  verte- 
bras are  more  often  diseased  than  the  lower.  It  is  most 
often  seen,  however,  in  the  dorsal  region  in  my  expe- 
rience. Injury,  as  in  all  other  surgical  manifestations  of 
tubercle,  plays  an  important  part  in  the  local  production 
of  the  disease,  but  it  often  follows  an  attack  of  scarlet 
fever,  measles,  whooping  cough,  or  other  disorder  which 


TUBERCULOUS    DISEASE    OF    BONE  73 

lowers  the  vitality  of  the  child,  and  there  is  no  doubt  that 
it  sometimes  arises  without  any  known  cause. 

The  Symptoms  vary  according  to  the  particular  part  of 
the  spinal  column  affected ;  as  a  rule,  they  are  not  well 
marked  in  the  early  stages,  and  they  may  pass  completely 
unnoticed.  The  symptoms  common  to  the  disease  in  all 
parts  of  the  spinal  column  are  rigidity,  the  result  of 
muscular  spasm.  The  rigidity  keeps  the  spine  fixed  so 
that  the  vertebral  movements  are  very  limited  in  every 
direction ;  the  child  walks  and  moves  stiffly,  and  turns  his 
body  with  care.  In  stooping  and  in  rising,  the  spine  is 
spared  at  the  expense  of  the  limbs.  The  diagnosis  of  the 
disease  in  its  earlier  periods  depends  greatly  upon  this 
muscular  rigidity,  and  the  child  cannot  be  considered  cured 
until  it  has  completely  disappeared.  Pain  is  an  early 
symptom ;  it  varies  greatly  in  intensity  as  well  as  in 
position.  It  is  elicited  by  sudden  movements  of  the 
segments  of  the  spine  upon  each  other,  and  the  patient 
is  therefore  careful  to  keep  his  muscles  in  a  state  of  tonic 
contraction.  It  is  often  worse  at  night,  and  it  wakes  the 
patient  as  soon  as  he  has  fallen  asleep. 

More  marked  symptoms  appear  as  the  disease  progresses. 
Some  amount  of  lateral  curvature  may  be  observed  in  the 
vertebral  column  even  before  there  is  any  projection  of  the 
spine,  and  this  is  best  seen  by  viewing  the  spine  as  a 
whole  against  a  dark  background.  Kyphosis  sooner  or 
later  becomes  apparent,  and  various  compensatory  changes 
then  take  place  in  the  skeleton.  The  character  of  the 
curve  depends  upon  the  number  of  the  vertebrae  affected, 
being  sharp  when  few,  and  round  when  many,  are  diseased. 
The  child  stumbles,  and  becomes  more  and  more  disinclined 
to  walk.  Chronic  abscesses  frequently  form,  more  often 
when  the  seat  of  the  disease  is  below  than  when  it  is 
above  the  level  of  the  diaphragm, 


74         THE    SURGICAL    DISEASES    OF    CHILDREN 

Nervous  Symptoms. — The  nervous  disturbances  asso- 
ciated with  caries  of  the  spine  have  recently  been  studied 
very  carefully  at  home  and  abroad,  for  they  have  gained 
in  importance  owing  to  the  surgical  treatment  which  has 
been  adopted  for  their  relief.  They  are  more  common 
when  the  laminae  and  posterior  parts  of  the  bodies  are 
affected,  so  that  they  are  often  present  when  there  is  but 
slight  deformity. 

The  symptoms  are  due  in  part  to  alterations  in  the 
nerve  roots  at  the  points  where  they  leave  the  spinal  canal, 
and  in  part  to  alterations  in  the  spinal  cord  itself.  They 
are  sometimes  due  to  tuberculous  inflammation  of  the 
lymphatic  tissues  about  the  arteries  of  the  cord  ;  some- 
times, but  very  rarely,  to  the  kyphosis  itself,  which  leads 
to  compression  of  the  cord  ;  sometimes,  when  the  paraplegia 
comes  on  suddenly,  it  is  due  to  fracture  of  the  carious 
vertebrae,  and  still  more  rarely  to  the  bursting  of  an 
abscess  into  the  spinal  canal,  to  haemorrhage  into  the 
canal,  or  to  the  presence  of  bony  sequestra  which,  by 
their  displacement,  press  upon  the  cord.  Most  frequently 
it  is  due  to  tuberculous  granulation  tissue  filling  up  the 
vertebral  canal,  and  causing  by  its  pressure  degenerative 
changes  either  in  the  nerves  or  in  the  spinal  cord.  The 
area  of  myelitis  in  these  cases  rarely  exceeds  an  inch  or  an 
inch  and  a  half  in  length,  but  the  completeness  of  the  com- 
pression is  often  seen  by  the  readiness  with  which  pulsation 
returns  in  the  cord  as  soon  as  the  granulation  tissue  has 
been  removed  in  the  course  of  a  laminectomy.  The  various 
nerve  symptoms  resulting  from  compression  in  cases  of 
spinal  caries  have  been  well  grouped  by  Dr.  Eskridge,  of 
Denver,8  from  whose  lectures  the  following  account  is 
condensed. 

The  pressure  upon  and  the  consequent  irritation  of  the 
nerve  roots  leads  to  an  early  loss  of  reflex  movements  in 


TUBERCULOUS    DISEASE    OF    BONE  75 

the  parts  supplied  by  the  affected  nerves,  though  in  the 
very  earliest  stages  there  is  often  an  exaggerated  plantar 
reflex.  The  alterations  in  sensation  are  usually  manifested 
sooner  than  the  motor  symptoms.  There  is  a  constant  or 
an  intermittent  pain  which  is  either  dull  and  aching  or 
sharp  and  neuralgic  in  character.  It  is  felt  radiating  over 
the  back  of  the  head  in  disease  of  the  upper  cervical 
region,  down  the  arms  in  the  upper  dorsal  region,  round 
the  abdomen  in  the  lower  dorsal,  and  down  one  or  both 
thighs,  along  the  course  of  the  sciatic  nerves,  in  disease  of 
the  lumbo-sacral  region.  The  pain  is  most  often  felt  in 
the  joints,  and  they  become  so  extremely  sensitive  that 
the  slightest  touch  upon  the  skin  causes  great  suffering. 
The  nerves  are  at  first  unaffected,  but  after  a  varying 
time  they  become  the  seat  of  a  descending  neuritis  which 
renders  them  tender,  and  at  the  same  time  prevents  them 
from  conducting  impulses,  so  that  the  patient  presents 
patches  of  greater  or  less  extent  which  are  anaesthetic 
when  touched,  but  are  the  seat  of  subjective  pain.  The 
motor  changes  come  on  later,  and  are  characterised  by 
gradual  weakening  and  wasting  of  the  muscles,  which 
may  lead  to  a  case  of  spinal  caries  being  mistaken  for 
progressive  muscular  atrophy,  if  the  wasting  is  a  more 
prominent  symptom  than  the  bone  lesions. 

The  trophic  disturbances  usually  come  on  later  still,  and 
when  the  disease  occurs  in  the  lower  cervical  and  upper 
dorsal  region  there  is  irregularity  of  the  pupil,  with  vaso- 
motor disturbances  and  sweating.  Herpes  zoster  is  only 
occasionally  seen. 

When  the  cord  is  affected  the  disease  is  usually  of  long 
standing,  and  the  paralysis  is  a  more  prominent  and  an 
earlier  symptom  than  the  sensory  affections.  The  paralysis 
is  generally  bilateral :  it  may  come  on  slowly,  or  its  onset 
may  be  sudden.    The  bladder  is  rarely  affected  in  the  more 


j6         THE    SURGICAL    DISEASES    OF    CHILDREN 

chronic  cases,  but  it  is  always  affected  when  the  paralysis 
appears  suddenly.  The  anaesthesia  may  be  complete  in 
cases  of  severe  compression  ;  but  the  sensory  changes,  as  a 
rule,  are  less  pronounced  than  the  motor,  and  in  the  latest 
stages  of  the  disease  there  are  often  marked  ataxic  symp- 
toms, even  when  the  paralysis  is  passing  off.  The  inter- 
costal muscles  and  the  diaphragm  are  sometimes  seriously 
affected  when  the  spinal  cord  is  compressed  in  the  upper 
cervical  region,  so  that  death  may  occur  directly  from  the 
effects  of  the  pressure,  or  indirectly  from  any  slight  pul- 
monary affection.  The  reflexes  are  exaggerated,  but  bed- 
sores are  not  formed  with  undue  readiness.  When  the 
lumbar  enlargement  is  compressed,  the  bladder  and  rectum 
become  paralysed,  the  knee-jerk  is  absent,  and  there  is 
great  wasting  of  the  paralysed  muscles. 

The  compression  due  to  tuberculous  disease  of  the  spinal 
column  must  be  distinguished  from  ordinary  myelitis  due 
to  inflammation  caused  by  tumours  in  which  the  trophic 
disturbances  are  generally  much  better  marked,  from 
haemorrhage  into  the  vertebral  canal,  and  from  syringo- 
myelia. The  cord  is  compressed  from  within  outwards  in 
syringo-myelia,  whilst  in  tuberculous  disease  the  pressure 
is  exercised  from  without  inwards.  The  absence  of  tem- 
perature and  pain  senses,  whilst  the  tactile  sensations 
remain  fairly  good,  the  absence  of  symptoms  due  to  disease 
of  the  bone,  or  to  pressure  upon  the  nerve  roots,  together 
with  the  prolonged  duration  of  the  disease,  are  sufficient  to 
distinguish  syringo-myelia  from  tuberculous  compression. 

Prognosis. — The  prognosis  in  cases  of  paraplegia  due 
to  pressure  is  fairly  good.  The  pain  remains  for  a  long 
time,  but  the  other  sensory  symptoms  improve,  whilst  the 
disappearance  of  the  paralysis  is  extremely  gradual ;  the 
appearance  of  cystitis  and  bedsores  necessarily  increases 
the  gravity  of  the  prognosis.      The  chances  of  complete 


TUBERCULOUS    DISEASE    OF    BONE  77 

recovery  are  greatest  when  the  dorsal  portion  of  the  cord 
is  compressed.  The  prognosis  in  these  cases  is  more 
favourable  when  absolute  paralysis  develops  rapidly  after 
the  appearance  of  symptoms  indicating  myelitis  than 
when  it  appears  more  gradually,  for  it  is  then  due  to  an 
inflammation  of  the  cord  which  may  subside,  rather  than 
to  gradual  changes  within  the  canal  which  tend  to  remain 
permanent. 

The  prognosis  of  spinal  caries  itself  is  grave,  but  by 
no  means  bad.  Recovery  may  take  place  without  sup- 
puration, but  with  anchylosis  of  one  or  more  vertebrae  ; 
or  septic  infection  may  lead  the  patient  to  the  very  brink 
of  the  grave,  and  leave  him  crippled  for  life.  Hoffa  gives 
a  mortality  of  27  cases  in  a  series  of  269,  and  says  that 
the  older  the  patient  the  worse  is  his  chance  of  recovery. 
Even  the  paralytic  symptoms  tend  to  recover  spontane- 
ously if  the  patient  be  put  under  favourable  conditions. 
Myers  has  shown  that  55  per  cent,  out  of  a  total  of  218 
cases  of  paraplegia  have  completely  recovered.  The  aver- 
age duration  of  the  paraplegic  symptoms,  in  connection 
with  disease  of  the  cervical  spine,  was  twelve  months ; 
in  the  upper  dorsal  region,  nine  and  a  half  months ;  in 
the  lower  dorsal,  six  months ;  and  in  the  lumbar,  eight 
months. 

The  Differential  Diagnosis  of  Pott's  disease  is  from 
rheumatic  spine,  hysteria,  scoliosis,  ricketty  curvature, 
typhoidal  spine,  sacro-iliac  and  hip  disease,  torticollis, 
acute  septic  osteomyelitis,  commencing  in  the  vertebrae ; 
gummatous  and  sarcomatous  infiltration  of  the  bodies,  and 
more  rarely  from  actinomycosis  leading  to  absorption  of 
the  vertebrae.  It  has  been  carefully  considered  by  Mr. 
Robert  Jones  and  Dr.  Ridlon  in  the  Provincial  Medical 
Journal  for  1802. 

Rheumatic  inflammation  in  children  runs  a  more  acute 


78 


THE    SURGICAL    DISEASES    OF    CHILDREN 


course  than  tuberculous,  the  pain  is  more  diffused  and 
is  not  increased  by  pressure,  and  there  is  not  the  same 
worn  facial  expression. 

Hysteria  is  recognised  by  the  absence  of  rigidity  and  by 
the  character  of  the  pain,  light  stimuli  often  being  more 
effective  in  producing  it  than  heavier  ones. 

Lateral  curvature  does  not  cause  rigidity  until  it  has 
lasted  for  a  long  time ;    the  pain  is  less,  the   deformity 


Fig.  8. — Diagram  of  a  child  with  spinal  caries.    It  shows  that  the  prominence 
does  not  disappear  during  extension  of  the  vertebral  column. 

[From  Hoffa's  "  Lehrbuch  der  Orthojiadinchen  Chirv/rgie."'] 

of  the  chest  is  asymmetrical,  and  the  curve  is  rather  a 
spiral  condition  of  the  vertebral  column  than  a  bending 
of  the  entire  trunk  as  in  Pott's  disease. 

In  ricketty  curvature  there  is  an  absence  of  pain, 
evidence  of  rickets,  and  sometimes  rigidity.  The  exact 
nature  of  the  curve  is  sometimes  to  be  proved  by  laying 
the  child  flat  upon  its  stomach,  and  then  raising  it  gently 
by  the  ankles  so  that  the  back  becomes  concave.  An 
angular   curvature   remains,   whilst   ricketty  and   lateral 


TUBERCULOUS    DISEASE    OF    BONE 


79 


curvatures  usually  disappear.  The  following  diagrams 
(figs.  8  and  9)  copied  from  Hoffa  show  this  difference. 

The  history  is  sufficient  to  recognise  spinal  curvature 
occurring  after  typhoid  fever,  which  sometimes  causes  a 
chronic  osteitis  some  months  after  the  acute  symptoms 
have  passed  away,  and  may  leave  a  life-long  deformity. 

Sacro-iliac  and  hip  disease  are  both  rather  likely  to  be 
mistaken  for  disease  of  the  lumbar  spine,  and  conversely, 


Fig.  9. — Diagram  of  a  child  with  ricketty  curvature  of  the  spine.     It  shows 
that  the  prominence  disappears  during  extension  of  the  vertebral  column. 
[From  Hoffa's  "  Lehrbuch."'] 

especially  if  a  psoas  abscess  has  caused  some  amount  of 
flexion  with  fixation  of  the  hip.  A  rectal  examination 
may  clear  up  a  doubtful  case  of  sacro-iliac  disease,  by 
demonstrating  the  presence  of  inflammatory  symptoms  in 
the  neighbourhood  of  the  joint ;  whilst  in  cases  in  which 
it  is  doubtful  whether  the  hip  or  spine  is  affected,  a 
careful  examination  of  the  movements  at  the  hip  will 
show  that  in  cases  of  lumbar  caries  with  an  abscess  all 
its  movements  are  free,  except  extension.     A  psoas  abscess 


8o         THE    SURGICAL    DISEASES    OF    CHILDREN 

itself  must  not  be  mistaken  for  a  perinephric  or  other  form 
of  chronic  abdominal  abscess. 

Wryneck  is  closely  simulated  by  caries  in  the  upper 
cervical  region.  In  wryneck,  however,  the  chin  points 
away  from  the  prominent  sterno-mastoid  muscle ;  in  caries 
it  points  towards  that  muscle  if  only  one  sterno-mastoid 
be  prominent.  The  movements  of  the  head  are  restricted 
in  all  directions  in  cervical  caries ;  in  torticollis  only  in 
one  direction — that  which  puts  the  shortened  muscle  on 
the  stretch. 

Acute  septic  osteomyelitis  originating  in  the  vertebrae 
runs  a  much  more  acute  course,  and  may  affect  a  very 
much  larger  number  of  vertebrae  than  does  caries.  The 
constitutional  symptoms  are  much  more  severe. 

Syphilitic  disease  of  the  spine  sometimes  occurs  at  two 
different  points  in  the  vertebras  separated  by  one  or  more 
healthy  vertebras,  whilst  such  healthy  intervals  less  often 
occur  in  tuberculous  disease.  It  may  co-exist  with  syphi- 
litic disease  of  other  joints,  and  it  is  amenable  to  the 
ordinary  anti-syphilitic  remedies. 

It  is  impossible  to  distinguish  sarcoma  of  the  spine 
from  spinal  caries  until  the  progress  of  the  case  or  the 
pressure  of  the  tumour  clears  up  the  doubt. 

Actinomycosis,  aneurism  of  the  dorsal  aorta,  and  hydatids 
of  the  spine  are  so  rare  in  England  that  they  do  not  enter 
into  the  question  of  diagnosis  in  children. 

Characters  of  Spinal  Caries  in  Different  Regions 
of  the  Vertebral  Column. 

It  is  essential  for  the  proper  examination  of  a  case  of 
spinal  caries  that  the  patient  should  be  stripped.  When 
cervical  caries  is  suspected,  Mr.  Jones  suggests  that  the 
patient  should  be  examined  by  placing  him  face  down- 
wards upon  his  parent's  knees.     If  disease  exists,  the  child 


TUBERCULOUS    DISEASE    OF    BONE  8 1 

will  not  let  his  head  drop,  even  though  the  examination 
be  prolonged,  and  if  he  be  placed  supine  he  will  show  no 
inclination  to  bend  his  head  towards  the  sternum  in  the 
first  act  of  rising. 

Pain  may  be  felt  in  the  chest,  or  running  up  the  back 
of  the  neck  and  head,  or  down  the  arms  in  caries  of  the 
cervical  spine.  An  abscess  is  not  frequent,  but  when  it 
is  present  it  may  point  either  behind  the  sterno-mastoid 
muscle  or  at  the  back  of  the  pharynx.  It  differs  ana- 
tomically from  the  retropharyngeal  abscess  due  to  sup- 
puration of  the  glands  and  connective  tissue  (p.  25)  in  the 
fact  that  it  lies  beneath  the  anterior  common  ligament. 

Dorsal  caries  is  the  commonest  form  of  disease.  In 
addition  to  the  ordinary  rigidity  and  difficulty  in  stooping, 
the  respiration  is  interfered  with,  and  the  child  pants. 
Lateral  deviation  of  the  vertebrae,  with  or  without  rota- 
tion, may  precede  the  angular  curvature  in  this  region. 
An  abscess  is  not  very  frequent  when  the  upper  dorsal 
vertebrae  are  affected;  but  when  it  appears,  it  points 
between  the  ribs,  some  little  distance  outside  the  spinous 
processes;  a  psoas  abscess  results  from  disease  of  the 
lower  dorsal  vertebrae.  The  pain  is  felt  as  a  girdle  pain 
or  stomach-ache. 

Lumbar  caries  is  less  common  than  dorsal,  but  more 
common  than  cervical  disease.  The  pain  is  felt  along  the 
front  and  inner  sides  of  the  thigh.  One  or  both  psoas 
muscles  may  become  spasmodically  contracted,  so  that  the 
disease  may  be  mistaken  for  hip  disease,  as  flexion  of  the 
joint  occurs  before  the  appearance  of  any  curvature.  Mr. 
Jones  gives  the  following  directions  for  recognising  flexion 
due  to  spinal  disease  :  "  The  patient  is  placed  prone  upon  a 
table,  the  pelvis  is  held  firmly  down  with  one  hand,  while 
with  the  other  hand  first  one  and  then  the  other  knee  is 
lifted  upwards.      The  freedom  with  which  they  can  be 


82         THE    SURGICAL    DISEASES    OF    CHILDREN 

raised,  and  the  difference  in  extent  of  movement,  or  the 
extent  to  which  each  of  them  differs  from  the  normal,  must 
be  noted.  Then,  with  one  hand  upon  the  back,  at  about 
the  tenth  dorsal  vertebra,  and  the  other  hand  lifting  up 
both  knees  at  the  same  time,  the  rigidity  of  that  part  of 
the  spine  is  noted.  It  is  upon  this  rigidity  that  the 
diagnosis  must  depend.  In  healthy  children  the  spine 
can  be  bent  backward  so  far  that  the  thighs  are  at  nearly 
a  right  angle  with  the  upper  dorsal  spine." 

Paraplegia  is  very  uncommon  in  disease  of  the  lumbar 
spine.  Abscess  is  frequent ;  it  may  pass  into  the  psoas 
muscle,  and  open  in  the  thigh  ;  or,  if  the  disease  is  below 
the  third  lumbar  vertebra,  the  pus  may  pass  into  the  sheath 
of  the  psoas  where  it  is  continuous  with  the  sacral 
end  of  the  pelvic  fascia,  so  that  it  tracks  down  to  the 
pyriformis,  and  leaves  the  pelvis  by  the  great  sacro- 
sciatic  foramen  to  point  in  the  buttock.  The  abscess 
sometimes  extends  laterally,  following  the  nerves,  and 
pointing  in  the  loin  some  inches  from  the  spine.  The 
chronic  abscess  appears  at  very  variable  periods  in  the 
disease,  sometimes  quite  early,  often  soon  after  the  ap- 
pearance of  the  spinal  deformity,  occasionally  not  until 
months  later ;  or,  if  it  be  a  "  residual "  abscess,  not  until 
years  after  the  patient  has  been  cured.  The  abscess 
does  not  necessarily  open,  for  it  is  no  uncommon  thing 
in  making  a  post-mortem  examination  to  find  one  psoas 
a  mere  shell  of  muscle  containing  caseating  or  even 
calcified  material,  associated  with  cured  disease  of  the 
spine,  resulting  from  simple  tuberculous  infection.  The 
infection  is  more  frequently  mixed,  and  the  abscess  then 
runs  an  ordinary  chronic  course,  pointing,  in  the  case  of 
a  psoas,  either  externally  or  internally  to  the  femoral 
sheath,  or  else  tracking  down  the  thigh  for  long  distances. 
The  projection  of  the  spine  is  sometimes  produced  quickly 


TUBERCULOUS    DISEASE    OF    BONE  83 

and  continues  to  alter  its  shape  for  a  considerable  period, 
whilst  at  other  times  it  only  forms  slowly,  and  hardly 
undergoes  any  subsequent  change.  The  amount  of  de- 
formity too  varies  greatly  ;  in  some  rare  cases  it  is  hardly 
perceptible,  whilst  in  others  it  is  so  marked  that  Shaw 
quotes  a  case  in  which  the  unfortunate  patient  could  only 
get  about  "  on  all-fours." 

Treatment.  (1)  Palliative.  —  The  'treatment  in  the 
earlier  stages  of  the  disease  is  essentially  palliative,  and 
exactly  the  same  methods  must  be  adopted  for  its  relief 
as  in  other  cases  of  tuberculous  osteitis.  Rest  is  there- 
fore a  matter  of  the  first  importance,  and  it  is  essential 
that   the  weight   of   the   body  should   be   taken   off  the 


Fig.  10. — Diagram  to  show  the  method  of  applying  a  plaster-of-Paria  case 
for  the  treatment  of  spinal  caries. 

[From  Hoffa's  "  Lehrlwsh."] 

spine.  These  indications  are  met  if  the  patient  can  be 
kept  absolutely  rigid  and  flat  in  bed  for  long  periods  of 
time.  Mere  rest,  indeed,  will  often  relieve  the  pain  and 
lessen  the  symptoms  of  paralysis,  putting  the  patient  in 
the  fair  way  towards  recovery ;  but  rest  alone  is  in- 
sufficient in  many  cases  where  the  spines  of  the  vertebrae 
have  already  become  prominent.  A  moderate  amount  of 
extension  must  then  be  maintained  by  moulding  a  convex 
splint  of  plaster-of-Paris,  leather,  gutta-percha,  or  in  very 
small  children,  of  poro-plastic  felt,  to  the  patient's  trunk, 
as  has  been  recommended  by  Reeves  and  Lorenz  (fig.  10). 
A  wicker-work  tray  is  often  sufficient  for  better-class 
patients.     The  splint  should  be  moulded  on  to  the  spine 


84         THE    SURGICAL    DISEASES    OF    CHILDREN 

whilst  the  child  is  upon  its  hands  and  knees  and  after 
the  surgeon  has  gently  placed  the  diseased  vertebras  in 
the  position  of  least  deformity.  A  jury-mast  is  necessary 
when  the  disease  is  above  the  eighth  dorsal  vertebra.  A 
double  Thomas  may  be  employed  in  place  of  the  moulded 
splint. 

When  the  pain   has  subsided,  when  the   surgeon  con- 
siders   that    there    is   no   longer    any    tendency    to   the 
formation  of  an  abscess,  when  the  child  has  regained  its 
colour  and  eats  heartily,  it  need  no  longer  be  kept  in  bed. 
A   rigid  jacket   made  of   light  material  should  then  be 
moulded  to  the  spine  whilst  the  vertebral  column  is  in 
a  state  of   gentle  extension,  and   the  patient  should   be 
encouraged  to  take  gentle  exercise.     Whatever  material 
is  used  for  the  jacket,  it  should  be  well  and  accurately 
adapted  to  the  body,  reaching  from  the  great  trochanters 
to  the  axillae,  provided  with  shoulder  straps,  and,  if  neces- 
sary, with  a  jury-mast.     A  skilfully  made  plaster-jacket 
meets  the  requirements   well,  if  care  be   taken  to  keep 
pressure  off  all  bony  points,  including  the  spinal  curvature, 
by  pads  of  felt.     As  soon  as  possible  the  hot  and  uncom- 
fortable jacket  should  be  replaced  by  a  properly  adjusted 
and  light  spinal  support,  which  must  be  worn  until  the 
absence  of  all  muscular  rigidity  in  the  spine  allows  it  to 
be  laid  aside,  for  only  then  will  complete  consolidation 
have  been  effected.     Some  modification  of  Taylor's  support 
(fig.    11)   is   often    used   for    this    purpose.      It   consists 
essentially  of  two  steel  uprights,  one  on  either  side  of  the 
spine,  with  a  cross-piece,  straps,  and  pads. 

(2)  Operative.— Many  cases,  however,  do  not  run  so 
smooth  a  course.  Abscesses  form,  the  pain  continues,  the 
disease  progresses,  and  symptoms  of  spinal  meningitis 
followed  by  myelitis  occur  in  spite  of  absolute  physiolo- 
gical rest  of  the  part.     Mr.  Arbuthnot  Lane,  Dr.  Macewen 


TUBERCULOUS    DISEASE    OF    BONE 


35 


and  Mr.  Thorburn  in  this  country,  Dr.  Chipault  and 
others  abroad,  have  followed  the  anti-tuberculous  treat- 
ment of  spinal  disease  to  its  logical  conclusion  by  cutting 
down  upon  the  vertebral  column,  removing  the  laminae 
over  the  affected  region,  and  scraping  away  the  granula- 
tion tissue  which  gives  rise  in  the  majority  of  cases  to 
the  paraplegic  symptoms.  This  treatment  is  especially 
useful  when  the  disease  is  limited  to  the  posterior  part 


Fig.  11.— Taylor's  brace  for  supporting  the  vertebral  column  in  spinal  caries 
after  the  plaster-jacket  has  been  laid  aside. 

of  the  vertebral  column ;  but  it  is  not  useful  in  every 
case  of  paraplegia  occurring  in  the  course  of  Pott's  disease. 
(1)  Indications  for  Operation.— Mr.  Thorburn  says 
that  the  indications  for  the  operation  of  laminectomy  are  a 
steady  increase  in  the  symptoms,  in  spite  of  favourable  con- 
ditions and  treatment ;  the  presence  of  symptoms  which 
directly  threaten  life,  such  as  secondary  chest  troubles  and 
intractable  cystitis ;  the  persistence  of  paraplegic  symptoms 


86         THE    SURGICAL    DISEASES    OF    CHILDREN 

after  the  original  pressure  lesion  has  ceased  to  act,  the 
symptoms  being  due  to  pressure  caused  by  scar  tissue  ; 
and  in  caries  of  the  posterior  part  of  the  spinal  column,  for 
in  these  cases  the  whole  of  the  tuberculous  tissue  can 
easily  be  removed,  and  the  condition  of  the  patient  can 
thus  be  materially  ameliorated.  The  operation  is  also  of 
service  when  severe  pain  is  rapidly  exhausting  the  patient. 
(2)  Contra-Indications. — Prof.  Macewen  very  properly 
holds  that  the  operation  of  laminectomy  should  not  be  per- 
formed when  active  tuberculous  changes  are  going  on  in 
other  organs  ;  in  cases  of  general  meningitis,  when  fracture 
has  followed  as  a  resialt  of  caries ;  and  when  the  symptoms 
of  paraplegia  have  suddenly  manifested  themselves. 

Laminectomy. 

The  operation  is  a  strictly  logical  one  if  our  theories  of 
the  pathology  of  tubercle  are  correct,  and  it  will  probably 
be  found  serviceable  in  some  cases.  It  should  not  be 
considered  as  a  matter  of  frequent  necessity,  for  many 
cases  of  paraplegia  due  to  spinal  caries,  which  appear 
suitable  for  laminectomy,  undergo  such  marked  improve- 
ment from  rest,  with  the  ordinary  methods  of  treatment, 
that  the  operation  becomes  unnecessary.  When  it  has  to 
be  performed,  however,  it  should  be  done  before  advanced 
secondary  changes  have  taken  place  in  the  cord,  so  that 
the  surgeon  ought  not  to  wait  too  long.  The  theoretical 
objection  attaches  to  it,  that  when  the  uninjured  parts 
are  removed  by  operation  and  the  remaining  parts  are 
softened  by  disease,  the  use  of  the  spinal  column  as  a 
support  is  lost.  This  argument  would  be  valid  in  the 
case  of  a  skeleton ;  but  in  the  body,  if  the  bone  is  removed 
sub-periosteally,  the  osseous  tissue  is  soon  replaced. 

The  Technique  of  laminectomy  is  simple.  The  child  is 
placed  upon  his  left  side,  an  incision  is  made  over  the 


TUBERCULOUS    DISEASE    OF    BONE  87 

projecting  part  of  the  spine,  the  soft  parts  are  separated 
upon  the  two  sides,  and  with  them  the  periosteum  covering 
the  vertebras,  until  two  or  three  laminae  are  thoroughly 
exposed.  One  lamina  is  then  divided  with  a  pair  of  strong 
cutting  forceps,  and  is  twisted  out  of  place  with  sequestrum 
forceps.  A  sufficient  number  of  laminae,  generally  two  or 
three,  and  if  necessary  the  vertebral  spines  and  the  laminae 
upon  the  opposite  side,  are  removed,  until  the  vertebral 
canal  is  clearly  exposed  to  view.  It  is  sometimes  found  to 
be  filled  with  tuberculous  granulation  tissue,  which  must 
be  carefully  removed  with  a  sharp  spoon,  the  bleeding 
being  arrested  as  far  as  possible,  and  care  being  taken  that 
the  blood  does  not  pass  down  into  the  canal.  The  spinal 
cord  lies  along  the  anterior  surface  of  the  vertebral  canal, 
and  at  some  distance  below  its  posterior  arch.  It  is  easily 
recognised  as  it  lies  in  its  membranes.  The  spinal  cord 
with  its  sheath  is  gently  drawn  aside  by  large  and  broad 
retractors,  until  the  posterior  surface  of  the  bodies  of  the 
diseased  vertebrae  are  exposed.  The  granulation  tissue  is 
again  scraped  away  as  completely  as  possible,  any  abscesses 
which  may  be  present  are  opened,  the  bones  are  swabbed 
with  a  solution  of  1  in  15  zinc  chloride,  and  the  wound  is 
afterwards  well  flushed  with  sterilised  water  at  a  tempera- 
ture of  105°  F.  The  cord  is  allowed  to  fall  back  into  place, 
and  the  surgeon  should  not  consider  that  he  has  done  his 
best  for  the  patient  until  he  sees  pulsation  in  the  cord,  for 
he  is  then  sure  that  every  source  of  constriction  has  been 
removed.  The  soft  parts  and  the  skin  are  brought  into 
accurate  apposition,  and  every  endeavour  is  made  to  obtain 
union  by  first  intention,  without  the  use  of  any  drainage- 
tube.  Sensation  is  restored  throughout  the  body  within 
a  few  days  of  the  operation,  whilst  motor  power  returns 
more  gradually.  Fistulous  tracts  are  liable  to  form  at  the 
seat  of  operation,  and  recurrence  of  the  symptoms  for  which 


88         THE    SURGICAL    DISEASES    OF    CHILDREN 

the  operation  was  originally  performed  has  taken  place  in 
some  of  the  cases. 

The  Treatment  of  Cold  Abscesses. 

The  large  cold  abscesses  which  so  often  occur  in  con- 
nection with  tuberculous  diseases  of  the  vertebrge  and  of 
the  hip  have  long  been  bugbears  to  surgeons,  and  in  pre- 
antiseptic  days  those  surgeons  treated  their  patients  best 
who  left  such  abscesses  alone.  The  abscesses  are  of  two 
kinds — those  containing  pus,  and  those  filled  with  caseous 
material.  The  ideal  method  of  treatment  for  both  forms  is 
to  dissect  them  out  cleanly  without  pricking  the  membrane 
which  surrounds  them  ;  but  they  are  often  so  extensive  and 
so  deeply  seated  that  this  can  only  be  done  in  exceptional 
instances.  Dissection  is,  however,  practicable  in  the  case  of 
those  caseating  collections  found  in  the  thigh  in  connection 
with  cured  or  stationary  disease  of  the  hip ;  but  if  it  be 
attempted  there  must  be  no  hesitation  and  no  mistake  upon 
the  part  of  the  surgeon,  for  the  operation  must  be  carried 
through.  If  the  mass  be  cleanly  removed,  the  wound  will 
heal  by  first  intention,  and  good  will  have  been  done ;  if, 
on  the  other  hand,  it  be  badly  removed,  and  a  part  be  left 
behind,  extensive  suppuration  is  almost  sure  to  follow ; 
for  if  it  be  pricked  and  some  of  the  caseating  material 
be  allowed  to  escape,  the  wound  may  become  infected,  and 
harm  will  have  been  done  to  the  patient,  for  the  scar  may 
become  the  seat  of  a  tuberculous  dermatitis,  and  it  must 
then  be  cut  out. 

Failing  the  adoption  of  the  ideal  method,  the  surgeon 
resorts  to  the  next  plan,  which  has  been  strongly  advocated 
by  Mr.  Barker,  and  which  is  now  very  generally  adopted, 
with  excellent  results.  The  abscess  or  caseous  collection 
is  laid  open  at  its  most  accessible  part,  and  the  contents 
are  allowed  to  escape.     The  surgeon  then  introduces  some 


TUBERCULOUS    DISEASE    OF    BONE 


89 


form  of  "  flushing-scoop  "  (fig.  12),  which  is  a  sharp  spoon 
provided  with  a  tubular  stem,  through  which  a  constant 
stream  of  fluid  can  be  passed  into  the  hollow  of  the  scoop. 
The  instrument  is  attached  to  an  irrigator 
containing  a  gallon  or  more  of  boric  solution 
at  a  temperature  of  105°  P.,  and  the  irri- 
gator is  attached  to  a  pulley  running  in  a 
block,  and  is  raised  and  secured  at  a  height 
of  about  five  feet  above  the  patient  as  he 
lies  upon  the  operating  table,  so  that  a  good 
head  of  water  may  be  obtained  for  the  flush- 
ing purposes.  The  scoop  is  then  introduced 
into  the  abscess,  and  its  walls  are  gently 
but  systematically  scraped,  the  fluid  being 
allowed  to  pass  through  the  scoop  either  con- 
tinuously or  at  intervals.  The  abscess  cavity 
is  thus  distended,  and  its  contents  as  they 
are  loosened  by  the  scoop  are  carried  out  of 
the  wound  by  the  reflux  stream.  The  surgeon 
must  exercise  care  and  discretion  in  using 
the  scoop,  for  if  he  is  too  rough  very  serious 
damage  may  be  done  to  the  parts. 

The  hot  solution  serves  two  purposes 
besides  that  of  removing  the  debris :  it  allows 
of  the  more  ready  removal  of  the  contents  of 
the  cavity  if  it  be  caseous,  and  at  the  same 
time  it  staunches  the  bleeding.  The  cavity 
is  squeezed  dry  as  soon  as  the  whole  of  the 
pyogenic  membrane  has  been  removed,  or 
the  drying  is  done  by  introducing  pieces  of 
absorbent  wool  freshly  wrung  out  of  a 
solution  of  boric  acid.  The  wound  is  then  closed  with 
sutures  of  horsehair,  and  is  dressed  antiseptically.  It  is 
better  not  to  use  a  drainage-tube.     This  treatment  cannot 


H 

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O 
O 

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be 

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90        THE    SURGICAL    DISEASES    OF    CHILDREN 

be  carried  out  to  its  full  exteut  in  many  cases  of  psoas 
abscess  ;  indeed,  it  only  gives  the  best  results  when  the 
bone  disease  is  quiescent  and  the  abscess  cavity  is  simple, 
and  even  then  it  may  be  necessary  to  repeat  the  operation. 
The  annexed  drawings  (figs.  13  and  14) — copied  from 
Hoffa— will  show  how  complex  these  abscesses  often  are, 
and  that  no  single  operation  would  be  sufficient  to  cure 
them.  Palliative  rather  than  curative  measures  must 
then  be  tried,  or  the  abscess  may  be  treated  piecemeal. 
I  usually  open  such  an  abscess,  scraping  and  flushing  it 
as  far  as  it  can  be  reached.  A  long  probe  is  then  passed 
upwards  from  the  groin  into  the  flank,  and  afterwards 
downwards  into  the  thigh.  It  is  made  to  project  beneath 
the  skin  in  both  situations,  and  counter-openings  are 
made.  Drainage-tubes  are  passed  from  the  counter- 
openings  to  the  wound  in  the  groin,  and  antiseptic 
dressings  are  applied ;  but  if  it  is  possible  the  edges  of 
the  wounds  should  be  pared  and  sutured  after  the  abscess 
cavity  has  been  rendered  aseptic.  Strict  cleanliness  is 
enforced,  and  little  by  little  the  drainage-tubes  are 
shortened,  so  that  the  wound  in  the  groin  heals  first. 
There  is  usually  no  difficulty  in  getting  the  wound  in  the 
femoral  part  of  the  abscess  to  close,  for  it  is  cut  off  from 
the  source  of  infection  ;  but  it  is  far  different  with  the 
iliac  part,  which  is  still  in  connection  with  diseased 
bone,  and  so  long  as  the  disease  progresses,  so  long  will 
pus  continue  to  be  formed.  The  after-treatment  will 
now  depend  upon  the  individual  case  ;  if  the  abscess  be 
comparatively  simple,  like  that  represented  in  fig.  13,  the 
opening  above  the  crest  of  the  ilium  may  be  enlarged,  and 
valuable  information  as  to  the  extent  of  the  disease  may 
be  obtained  by  digital  exploration,  even  to  the  extent  of 
finding  a  sequestrum,  which  should  be  removed  if  it  is 
possible. 


TUBERCULOUS    DISEASE    OF    BONE 


91 


This  method  is  inapplicable  when  the  abscess  forms  a 
series  of  lagoons  and  canals,  like  that  represented  in  fig.  14. 


Fig.   13. — A  large  psoas  abscess  dissected  to  show  the  relations  it  bears  to 
the  various  anatomical  structures  in  its  neighbourhood. 
[From.  Hoffa's  "  Lehrbuch."~\ 

Two  courses  are  then  open  to  the  surgeon.      He  may  cut 
down  upon  the  diseased  vertebrse  if  he  feels  pretty  sure 


92         THE    SURGICAL    DISEASES    OF    CHILDREN 

that  the  discharge  is  kept  up  by  the  presence  of  a  seques- 
trum, and  so  remove  the  source  of  irritation  ;  or  if  he  be 
less  certain  of  his  diagnosis,  he  may  content  himself  with 
scraping  the  sinus  and  injecting  it  with  an  emulsion  of 
iodoform  or  with  camphorated  naphthol.  The  treatment 
of  psoas  abscess  in  this  stage  is  still  unsatisfactory.     Such 


Fig.  14.— Diagram  of  a  double  psoas  abscess  to  show  its  loculated  character. 
[From  Hoffa's  "  Lehrbuch."] 

improvements,  however,  have  recently  been  made  in  our 
methods  of  treating  these  conditions  that  we  need  have  no 
fear  that  we  have  arrived  at  the  end  of  our  surgical 
resources,  but  we  may  feel  assured  that  in  due  time  a 
satisfactory  cure  will  be  found  even  for  the  last  stage  of 
a  loculated  psoas  abscess. 


TUBERCULOUS    DISEASE    OF    BONE  93 

HYPERTROPHIC  PULMONARY  OSTEO- 
ARTHROPATHY.'' 

Under  this  very  cumbersome  title  occur  certain  interest- 
ing cases  of  hypertrophy  of  the  bones  and  joints. 

Pathology.— The  hypertrophy  may  be  due  to  a  benign 
form  of  tuberculous  affection,  in  which  there  is  no  tendency 
to  break  down  or  caseate,  caused  perhaps  by  toxines  pro- 
duced during  the  inflammation.  It  occurs  in  children  as 
well  as  in  adults,  but  very  rarely  in  females. 

Symptoms. — The  hands  and  feet  are  always  greatly  and 
symmetrically  enlarged,  the  increase  in  size  involving  also 
the  lower  part  of  the  forearms  and  legs,  implicating  the 
bones  more  than  the  soft  parts,  and  markedly  affecting 
the  terminal  phalanges,  over  which  the  expanded  nails  are 
spread  out  with  a  transverse  and  longitudinal  curve,  so  as 
to  be  very  convex.  The  nails  themselves  are  large,  and 
bending  over  the  ends  of  the  fingers  give  them  a  great 
resemblance  to  the  beak  of  a  parrot ;  they  are  usually 
striated  longitudinally.  Various  long  bones  are  often 
hypertrophied,  especially  at  their  ends,  and  effusion  of 
fluid  into  the  knees  and  other  joints  is  not  uncommon 
The  disease  in  children  may  be  limited  to  the  phalanges. 
The  skull  remains  unaffected.  Scoliosis  is  common,  and  it 
is  not  rare  to  meet  with  kyphosis  affecting  the  lower  dorsal 
region.  The  disease  is  generally  of  insidious  onset  and 
long  duration  ;  but  it  sometimes  runs  a  rapid  course,  and 
in  all  or  nearly  all  the  cases  is  accompanied  by  some  form 
of  chronic  bronchial,  pulmonary,  or  pleural  disease,  es- 
pecially empyema. 

Diagnosis. — It  has  to  be  distinguished  from  acromegaly, 
osteitis  deformans  and  myxcedema.  There  is  no  intrinsic 
danger  to  life,  and  the  primary  and  causal  condition  not 


94         THE    SURGICAL    DISEASES    OF    CHILDREN 

being  of  necessity  fatal,  the  ultimate  result  cannot  be 
observed.  There  is  no  tendency  to  acute  inflammation  or 
to  suppuration  of  the  affected  bones  or  joints.  Relief  of 
the  pulmonary  condition  appears  to  react  beneficially  upon 
the  complication. 


EXPLANATION  OF  PLATE. 

Fig.  1. — A  section  through  the  right  shoulder  joint  to  show 
the  relation  of  the  synovial  membrane  to  the  upper  epiphysis  of 
the  humerus.  The  synovial  membrane  on  the  inner  side  comes 
below  the  epiphyseal  line,  but  it  stops  above  at  the  anatomical 
neck,  and  is  separated  from  the  synovial  sheath  of  the  biceps. 

Fig.  2. — A  vertical  section  through  the  elbow  joint  at  the  age 
of  eighteen  months,  showing  the  lower  epiphysis  of  the  humerus, 
and  the  upper  epiphysis  of  the  ulna,  and  their  relation  to  the 
synovial  membrane  of  the  elbow  joint.  (After  a  drawing  made 
by  Mr.  Jno.  Hutchinson,  jun.) 

Fig.  3. — Section  through  the  left  hip  joint  to  show  the  relation 
of  the  synovial  membrane  and  capsular  ligament  to  the  articular 
surface  and  to  the  epiphyses. 

Fig.  4.  — Section  of  the  left  knee  to  show  the  relation  of  the 
synovial  membrane  to  the  articular  surface,  and  to  the  epiphyses 
of  the  femur  and  tibia. 

Fig.  5. — A  section  through  the  ankle  joint  to  show  the  rela- 
tion of  the  synovial  membranes  to  the  epiphyses  and  to  the 
astragalus. 

(All  the  figures  are  semi-diagrammatic.) 


96 


m   Im 

I  \     /• " 


L -■■■•'•'• 


Fig-  S- 


DIONS   OF  Joints   SHOWING   THE    RELATION 

ok  the  Synovial  Membranes. 


CHAPTER    VI 

TUBERCULOUS  DISEASES   OF   JOINTS 
AND   BURS^E 

Morbid  Anatomy. — Tuberculous  disease  of  the  joints7 
is  very  frequent  in  children.  It  is  most  often  local,  but  it 
may  be  part  of  a  general  tuberculosis.  The  inflammation 
commences  either  in  the  synovial  membrane,  or  more 
often  in  the  ossifying  tissue  of  the  head  of  the  bone 
from  which  the  joint  becomes  secondarily  affected  by  its 
extension.  The  frequency  with  which  the  joints  are 
affected  by  this  process  depends  directly  upon  the  anato- 
mical relations  of  the  epiphyseal  line  to  the  capsule  of  the 
joint — relations  which  I  have  endeavoured  to  make  clear 
in  the  semi-diagrammatic  representations  in  the  coloured 
plate.  It  will  be  seen  that  the  line  of  the  epiphysis  in  the 
hip  and  in  the  lower  end  of  the  humerus  is  always  within 
the  capsule.  Tuberculous  disease  of  these  joints  is  there- 
fore frequent,  as  a  result  of  inflammation  of  their  epiphyses. 
The  capsule  is  only  partially  attached  to  the  line  of  the 
epiphysis  in  the  shoulder  and  in  the  lower  end  of  the 
femur,  so  that  these  joints  may  escape,  although  the 
epiphyseal  lines  are  diseased.  This  is  not  often  the 
case,  however,  as  the  union  between  the  capsule  and 
the  epiphysis  is  extensive.  The  capsule  of  the  knee  is 
attached  above  the  upper  tibial  epiphysis ;  this  joint  often 

escapes,    therefore,    even  when    there    has   been  a   sharp 

97  H 


98         THE    SURGICAL    DISEASES    OF    CHILDREN 

attack  of  tuberculous  inflammation,  involving  the  upper 
epiphyseal  line.  In  the  ankle  the  line  of  the  lower  epiphy- 
sis of  the  tibia  is  external  to  the  capsule,  but  the  astraga- 
lus and  the  lower  epiphysis  of  the  fibula  are  within  it. 
The  disease,  therefore,  usually  spreads  upwards  into  the 
joint  from  the  tarsus,  as  the  lower  end  of  the  fibula  is  not 
often  the  seat  of  tuberculous  inflammation. 

The  appearances  in  the  joint  vary  according  to  the 
character  of  the  disease.  When  the  inflammation  com- 
mences in  the  synovial  membrane,  there  may  be  a  general 
thickening  or,  more  rarely,  a  local  hypertrophy  of  its 
tissue.  Suppuration  takes  place  in  some  cases,  whilst 
in  others  the  synovial  membrane  secretes  a  clear  fluid, 
which  distends  its  cavity  and  leads  to  the  condition  known 
as  hydrops  articuli ;  indeed,  all  chronic  effusions  into  the 
joints  of  children  should  be  regarded  with  very  grave 
suspicion,  for  they  are  nearly  always  tuberculous.  Certain 
secondary  changes  take  place  both  outside  and  within  the 
joint.  The  thickened  synovial  fringes  may  caseate,  or 
they  may  become  oedematous,  and  grow  over  the  articu- 
lar surfaces,  leading  to  softening  of  the  ligaments  and 
destruction  of  the  cartilages.  The  connective  tissues 
surrounding  the  joint  either  undergo  a  gelatinous  trans- 
formation or  a  fibroid  thickening,  and  in  this  manner  a 
typical  white  swelling  is  produced.  Intra-articular  or 
peri-articular  abscesses  form,  and  the  joint  is  destroyed. 

The  changes  in  the  bone  are  of  the  same  general  charac- 
ter as  those  in  the  synovial  membrane.  A  deposit  of 
tubercle  takes  place  at  some  part  of  the  epiphyseal  line. 
This  either  caseates,  or  fungates,  or  suppurates,  until,  in 
young  children,  the  inflammation  extends  through  the  thin 
epiphysis  and  sets  up  an  arthritis.  The  inflammatory 
products  in  older  children  may  pass  into  the  joint  by  less 
direct  methods,  usually  round  the  edge  of  the  capsule.     In 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E    99 

a  few  cases  the  joint  escapes,  but  its  movements  are 
seriously  hampered  by  the  osteophytes  formed  by  the 
osteoplastic  periostitis  which  the  inflammation  causes. 
The  cartilages  become  destroyed,  either  piecemeal  by  a 
process  of  ulceration,  or  more  rarely  by  actual  necrosis. 
Granulations  spring  from  the  ends  of  the  inflamed  bone, 
and  if  the  patient  is  under  the  best  possible  conditions, 
bony  anchylosis  takes  place  in  a  good  position.  Faulty 
position  and  fibrous  anchylosis  is  very  common  in  this 
form  of  joint  disease,  or  the  suppuration  is  so  prolonged 
and  extensive  as  to  lead  to  death  or  to  a  necessity  for 
amputation. 

Symptoms. — The  individual  symptoms  will  be  found 
described  under  each  joint.  The  general  symptoms  com- 
mon to  all  forms  of  tuberculous  arthritis  are  rigidity, 
swelling,  fluctuation,  pain,  flexion,  shortening  and  dis- 
placement. The  swelling  is  a  constant  symptom  of  joint 
disease,  and  it  is  seen  more  early  in  exposed  joints,  like 
the  knee  and  elbow,  than  in  those  which  are  more  deeply 
situated,  like  the  hip  and  shoulder.  The  swelling  is  the 
result  of  effusion  into  the  joint,  of  hypertrophy  of  the 
synovial  membrane,  or  to  oedema  and  caseation  in  the 
connective  tissues  outside  the  joint.  The  wasting  of  the 
muscles  above  and  below  the  joint  always  makes  it  appear 
to  be  greater  in  the  knee  than  it  is  in  reality.  This  can 
easily  be  proved  by  taking  comparative  measurements 
round  the  two  limbs  at  similar  points  above,  over,  and 
below  the  affected  joint.  The  fluctuation  varies  greatly. 
It  is  best  marked  in  cases  of  simple  synovial  disease,  and 
it  is  least  marked  or  absent  when  the  swelling  is  due  to 
extra-articular  changes. 

The  pain  is  often  a  characteristic  symptom,  for  it  occurs 
in  severe  attacks  at  the  instant  when  the  patient  falls 
asleep,  and  is  one  cause  of  the  "  night-screaming  "  which 


IOO     THE    SURGICAL    DISEASES    OF    CHILDREN 

accompanies  many  of  the  chronic  inflammations  in  chil- 
dren's joints.  The  pain  appears  to  be  produced  by  the 
momentary  approximation  of  the  two  ends  of  the  inflamed 
bone,  owing  to  the  relaxation  of  the  tonic  contraction  in 
which  the  child  keeps  its  muscles  so  long  as  it  is  con- 
scious. It  is  therefore  usually  seen  when  the  cartilages 
have  ulcerated,  and  it  can  often  be  overcome  by  mechani- 
cally separating  the  inflamed  surfaces  of  the  joint  with 
an  extension  apparatus,  but  not  always,  for  it  appears 
to  be  sometimes  associated  with  the  changes  which  precede 
the  formation  of  an  abscess.  The  pain  may  also  be  elicited 
by  movement,  and  by  pressure  upon  the  part. 

Flexion  is  often  an  important  symptom  of  joint  disease, 
and  it  is  associated  with  the  rigidity  of  the  muscles, 
which  is  one  of  the  earliest  and  most  persistent  symptoms 
of  a  joint  lesion.  So  long  as  rigidity  lasts,  so  long  is 
there  progressive  joint  disease,  and  the  child  should 
not  pass  away  from  the  surgeon's  care  until  this  symptom 
has  disappeared.  The  pathology  of  the  muscular  rigidity 
is  just  beginning  to  be  understood,  and  it  appears  to 
be  due  to  reflex  irritation  originating  in  the  inflamed 
articular  surfaces,  and  is  part  of  the  general  process  leading 
to  that  atrophy  of  all  the  tissues  which  may  result  in  a 
shortened  limb,  even  when  there  has  been  no  absorption  or 
removal  of  the  articular  bone.  The  muscular  changes  may 
be  so  advanced  as  to  lead  to  a  marked  fibroid  change, 
rendering  them  useless.  Shortening  is  partly  due  to  the 
displacement  which  often  accompanies  disease  of  the  joints, 
and  partly  to  trophic  disturbances.  The  displacement  is 
usually  only  partial,  as  in  the  case  of  the  hip  and  knee, 
but  it  is  occasionally  a  true  dislocation. 

Diagnosis. — The  diagnosis  of  tuberculous  arthritis  in 
children  is  not  difficult ;  but  if  the  case  be  seen  early,  and 
is  at  all  doubtful,  a  careful  examination  should  be  made 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E  IOI 

under  an  anaesthetic  to  ascertain  the  exact  power  of  move- 
ment which  the  joint  possesses. 

Prognosis. — The  tendency  of  tuberculous  arthritis  is 
towards  destruction  of  the  joint,  with  subsequent  anchy- 
losis of  the  two  surfaces  either  by  bony  or  fibrous  tissue, 
and  often  in  a  bad  position.  In  many  cases,  however,  the 
patient  who  is  left  to  nature  may  die  before  this  process  is 
completed  from  the  effects  of  the  long-continued  suppura- 
tion attendant  upon  a  mixed  tuberculous  infection.  The 
inflammatory  changes  lead  to  alterations  in  the  growth  and 
the  functions  of  the  affected  parts,  and  the  surgeon  has  to 
guard  against  these  in  treating  such  cases.  Relapses  and 
local  recurrences  are  of  very  frequent  occurrence  in  all 
cases  of  tuberculous  arthritis. 

Treatment. — The  recognition  of  tubercle  as  a  locally 
infective  disease  has  materially  modified  the  treatment  of 
the  tuberculous  disease  of  joints  within  the  last  ten  years. 
There  existed  formerly  only  excision  and  amputation ;  ex- 
cision dating  back  at  least  to  the  time  of  Paulus  iEgineta, 
and  amputation  which  is  coeval  with  surgery.  The  treat- 
ment by  rest  must  also  have  been  employed  from  time 
immemorial.  Increased  knowledge  has  taught  us  that  the 
tubercle  bacillus  causes  lesions  which  have  in  themselves 
no  tendency  to  suppurate,  but  rather  to  undergo  caseous 
changes.  The  infection  in  many  cases  is  not  simple,  but 
the  tubercle  bacillus  has  various  septic  micro-organisms 
mixed  with  it,  and  these  are  pus-producing.  Still  further 
investigation — but  of  this  we  are  not  so  sure — tends  to  prove 
that  the  caseous  masses  in  tubercle  are  in  reality  the  dead 
and  degenerate  remains  of  the  white  corpuscles  which  have 
been  destroyed  in  an  endeavour  to  limit  the  spread  and 
the  multiplication  of  the  bacilli,  the  destruction  being 
brought  about  by  the  poisonous  secretions,  or  toxins, 
manufactured  for  defensive  purposes  by  the  micro-organ- 


102      THE    SURGICAL    DISEASES    OF    CHILDREN 

isms.  The  destruction  of  the  bacilli  is  thought  to  be 
carried  out  by  the  great  digestive  powers  with  which  the 
white  blood  corpuscles  are  endowed.  If  this  be  the  cor- 
rect interpretation  of  the  pathology  of  tubercle,  the  treat- 
ment of  tuberculous  disease  by  "  Sderogeny  "  is  founded 
upon  the  most  secure  and  scientific  principles.  This 
method  was  introduced  into  surgery  by  Prof.  Lannelongue 
in  1891.  It  consists  in  the  injection  into  the  tissues  near 
the  tuberculous  foci  of  a  solution  of  zinc  chloride.  The 
irritation  produced  by  this  reagent  leads  to  an  increase  in 
the  number,  and  an  alteration  in  the  character,  of  the 
white  corpuscles  in  the  tissues,  which  in  turn  react  upon 
the  tuberculous  nodules,  leading  to  their  destruction. 
This,  at  any  rate,  is  the  theoretical  explanation  ;  the  point 
of  surgical  interest  is  that,  after  such  injections,  the  tuber- 
culous foci  sometimes  undergo  a  retrograde  process,  and 
become  converted  into  fibrous  tissue,  which  may  afterwards 
be  dealt  with,  if  it  be  necessary,  in  the  ordinary  manner. 

(1)  Sderogeny. — The  details  of  the  operation  in  the  case 
of  the  knee  or  shoulder  are  the  following : — The  patient 
is  anaesthetised,  as  the  injections  are  painful,  and  the  part 
having  been  thoroughly  cleansed  in  the  usual  manner,  a 
drachm  of  zinc  chloride  solution,  of  the  strength  of  1  in 
10,  is  taken  up  in  an  aseptic  hypodermic  syringe.  The 
canula  of  the  syringe  is  first  wiped  dry.  This  is  important, 
as  any  of  the  solution  remaining  on  its  outside  will  destroy 
the  skin  and  tissue  in  the  track  of  the  needle.  It  is  then 
pushed  through  the  skin  and  the  tissues  until  its  point 
touches  the  bone  outside  the  synovial  membrane.  The 
point  is  withdrawn,  and  four  minims  of  the  solution  are 
forced  out  into  the  peri-articular  connective  tissue.  The 
injections  are  repeated  at  different  points  round  the  joint 
until  about  half  a  drachm  of  the  solution  has  been  used, 
care  being  taken  in  each  case  that  none  of  the  fluid  enters 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.ii   IO3 

the  cavity  of  the  articulation,  and  also  that  the  injections 
are  made  at  the  parts  where  the  synovial  membranes  re- 
ceive their  chief  blood  supply,  i.e.  at  the  reflection  of 
the  synovial  membrane  on  to  the  bone  and  along  the  great 
ligaments  of  the  joint.  When  the  part  to  be  injected  lies 
superficially,  the  syringe  should  be  directed  obliquely  to 
prevent  any  reflux  of  fluid.  In  no  case  must  an  injection 
be  made  directly  under  the  skin,  and  it  stands  to  reason 
that  the  large  arteries  and  nerves  are  to  be  avoided. 

The  parts  should  be  firmly  bandaged  after  the  operation, 
to  limit,  as  far  as  possible,  the  congestion  and  cedema ; 
and  if  there  be  much  pain,  a  hypodermic  injection  of 
morphia  must  be  given.  There  is  usually  a  pretty  sharp 
reaction,  which  subsides  by  the  third  or  fourth  day.  The 
limb  is  put  up  in  a  plaster  case,  and  in  the  most  favour- 
able position,  as  soon  as  the  inflammatory  symptoms  have 
subsided.  The  symptoms  of  sclerogeny — hardening,  and 
retrogressive  changes — are  generally  well  marked  in  three 
weeks  to  two  months  after  the  operation,  and  from  this 
time  onwards  the  muscles  should  be  regularly  shampooed 
and  galvanised.  A  single  series  of  injections  is  alone 
necessary  in  a  successful  case ;  but  if  the  operation  has  to 
be  repeated,  an  interval  of  at  least  three  weeks  should  be 
allowed  to  elapse.  Prof.  Lannelongue  claims  that  in  suc- 
cessful cases  the  results  are  most  satisfactory,  whilst  in  the 
less  successful  ones  the  injections  pave  the  way  for  further 
operations  of  a  more  radical  nature.  I  am  giving  the  method 
an  extensive  trial,  but  it  is  too  soon  to  dogmatise  upon  it. 

Many  other  methods  have  been  adopted  to  secure  the 
same  ends,  with  a  greater  or  less  amount  of  success.  Thus  a 
tincture  of  iodine,  2  per  cent,  solution  of  carbolic  acid,  a  1  in 
4  emulsion  of  balsam  of  Peru  made  up  with  sweet  almonds, 
a  solution  of  iodoform  in  glycerine  or  olive  oil,  and  the 
liqueur  de  Villate,  consisting  of  equal  parts  of  zinc  sulphate 


104      THE    SURGICAL   DISEASES   OF    CHILDREN 

and  copper  sulphate,  with,  a  little  Goulard  extract   and 

dilute  acetic  acid,  have  at  different  times  been  employed. 

The  iodoform  emulsion  is  made  according  to  the  following 

formula  : — 

1£>  Iodoform 10  parts 

Glycerine 70      „ 

Water 10      „ 

Wash  the  powdered  crystalline  iodoform  in  a  1  in  2000 
solution  of  corrosive  sublimate,  and  then  rub  it  up  with 
enough  spirit  to  prevent  its  becoming  lumpy.  Shake  the 
iodoform  and  water  together,  and  then  add  the  glycerine. 

Prof.  Senn  injects  the  iodoform  emulsion  directly  into 
the  cavity  of  the  joint  after  removing  the  synovial  fluid  or 
tuberculous  pus,  and  washing  out  the  cavity  with  a  3-5  per 
cent,  solution  of  boric  acid.  He  continues  the  injections  at 
intervals  of  a  week  or  two,  until  there  is  distinct  evidence 
of  diminished  tuberculous  inflammation.  The  improve- 
ment usually  manifests  itself  after  the  third  or  fourth 
injection.  I  thought  a  few  years  ago  that  I  obtained  good 
results  after  the  use  of  iodoform  emulsions  in  the  treat- 
ment of  tuberculous  abscesses ;  but  I  believe  now  that  the 
most  satisfactory  method  is  to  scrape  away  all  the  tuber- 
culous material  with  a  sharp  spoon,  and  endeavour  to 
obtain  union  by  first  intention. 

(2)  Rest. — The  treatment  of  tuberculous  disease  of  joints 
by  rest  is  frequently  attended  by  excellent  results  in  chil- 
dren, due  no  doubt,  in  part,  to  the  fact  that  it  allows  the 
tissues  time  to  deal  effectively  with  the  tubercle  bacillus, 
and  partly  because  it  abolishes  the  reflex  stimulus  leading  to 
trophic  disturbance.  This  method  of  treatment  is  especi- 
ally satisfactory  in  cases  where  the  synovial  tissue  is  alone 
or  chiefly  affected.  It  is  only  of  slight  use  where  the 
bones  are  extensively  diseased,  and  where  there  is  much 
deformity,  unless  the  deformity  be  due  to  fibrous  bands 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E    IC5 

which  yield  to  extension.  Good  as  the  method  is,  however, 
it  is  liable  to  abuse  if  it  be  adopted  too  exclusively  and  for 
unsuitable  cases.  The  worst  cases  of  lardaceous  disease 
which  have  recently  come  under  my  notice  have  been 
those  in  which  the  expectant  treatment  has  been  con- 
scientiously carried  out  in  patients  who  had  abscesses  and 
sinuses  which  it  was  impossible  to  render  aseptic. 

Acute  abscesses  must  be  opened  as  soon  as  possible  in 
a  child  who  has  been  treated  for  tuberculous  arthritis 
by  rest.  The  contents  of  the  abscess  must  be  evacuated, 
and  an  attempt  made  to  obtain  union  by  first  intention ; 
for  it  should  be  clearly  understood  that  many  of  the  effects 
of  tuberculous  disease  are  due  to  the  septic  rather  than 
to  the  tuberculous  bacilli.  Nature,  too,  in  many  cases  does 
not  give  such  good  results  as  can  be  obtained  in  a  shorter 
time  by  surgical  treatment  judiciously  applied.  Care, 
therefore,  should  be  taken  in  the  employment  of  this 
method.  On  the  one  hand,  rest  should  be  adopted  as  a 
routine  proceeding  in  all  cases  of  incipient  joint  disease  in 
children  ;  on  the  other  hand,  if  after  its  adoption  there  is 
not  marked  improvement,  if  the  disease  is  progressive,  if 
abscesses  form  which  cannot  be  effectively  dealt  with,  or 
if,  after  sufficient  trial,  relapses  occur  as  often  as  the 
patient  is  allowed  to  get  about,  it  should  not  be  persisted 
in,  but  recourse  should  be  had  to  the  more  radical  measures 
of  arthrectomy  or  excision. 

(3)  Operation. — It  is  the  duty  of  the  surgeon  to  cut  down 
upon  the  bone,  and  to  remove  any  caseating  masses  when 
rest,  sclerogeny,  and  the  allied  methods  have  failed.  He 
must  operate  at  once  when  he  suspects  that  a  tuberculous 
focus  is  present  in  the  epiphyseal  line.  He  is  especially 
bound  to  do  this  when  the  disease  affects  the  posterior 
part  of  the  head  of  the  humerus,  the  upper  or  lower  epi- 
physes of  the  tibia,  the  popliteal  surface  of  the  femur,  and 


106      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  upper  part  of  this  bone,  particularly  when  the  great 
trochanter  is  alone  involved.  The  operation  should  be  per- 
formed upon  a  limb  which  has  been  rendered  bloodless  by 
the  application  of  an  Esmarch's  bandage.  The  bone  should 
be  exposed,  and  should  be  gouged  away  in  the  neighbour- 
hood of  the  epiphysis.  When  the  diseased  tissue  is  ex- 
posed, it  should  be  removed,  and  the  cavity  in  which  it 
lay  should  be  swabbed  out  with  a  1  in  15  solution  of  zinc 
chloride.  It  should  be  thoroughly  flushed  with  boiled 
water,  packed  with  gauze,  and  allowed  to  granulate.  I 
have  recently  been  trying  the  effect  of  packing  such  tuber- 
culous cavities  and  sinuses  with  camphorated  naphthol, 
taking  care  never  to  introduce  more  than  four  drachms  at 
a  time,  lest  poisonous  symptoms  should  result.  The  direc- 
tions for  making  the  preparation  will  be  found  on  page  8. 
The  results  are,  I  think,  a  little  better  than  those  obtained 
from  packing  with  cyanide  gauze. 

Sternoclavicular  Joint. 

Frequency.  —  Inflammation  of  the  sterno-clavicular 
joint 10  is  one  of  the  rarest  forms  of  tuberculous  arthritis. 
It  may  occur  in  young  adults,  but  there  is  no  case  on  record 
in  which  it  has  been  seen  in  infants  It  is  either  primary, 
when  it  commences  as  a  synovitis,  or  it  is  secondary  to 
tuberculous  caries  of  the  clavicle. 

Symptoms. — Pain  is  the  earliest  symptom  of  the  dis- 
ease, and  it  is  of  such  a  nature  as  to  compel  the  patient  to 
assume  the  position  which  is  thought  to  be  characteristic 
of  a  broken  collar-bone.  He  supports  his  bent  elbow  in 
his  hand  to  take  off  the  weight  of  the  arm,  and  inclines 
his  head  to  the  affected  side  to  relax  the  tension  of  the 
muscles.  Sooner  or  later,  a  swelling  appears  over  the 
sterno-clavicular  end  of  the  joint,  and  it  is  a  typical  tumor 
albus.    It  is  oval  in  shape,  with  its  long  axis  lying  parallel 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E    IO7 

with  the  clavicle.  The  skin  is  distended  over  it,  but  it  is 
unaltered  in  character,  except  that  it  is  traversed  by  a  few 
veins  which  are  rather  more  conspicuous  than  usual.  It 
feels  doughy.  The  temperature  is  not  warmer  than  the 
surrounding  parts.  Careful  examination  will  show  that  it 
projects  behind  the  articulation  as  well  as  in  front  of  it, 
and  in  this  stage  it  is  likely  to  be  mistaken  for  a  sarcoma. 
It  eventually  suppurates,  and  leads  to  sinuses  in  the 
thoracic  wall.  The  sternal  end  of  the  clavicle  may  be  dis- 
placed, and  in  some  rare  cases  the  abscess  has  been  known 
to  point  and  open  into  the  mediastinum  or  into  the  pleura, 
or  it  may  even  lead  to  ulceration  of  the  great  venous 
trunks  lying  in  its  immediate  neighbourhood. 

The  Treatment  consists  in  cutting  down  upon  the  swell- 
ing, removing  all  the  f ungating  tissue,  and  sterilising  the 
cavity  as  far  as  possible,  so  as  to  enable  it  to  heal  by 
healthy  granulations. 

Tuberculous  Disease  of  the  Shoulder. 

Frequency  and  Course. — The  shoulder  is  less  fre- 
quently affected  than  the  other  large  joints,  for  it  only 
forms  25  per  cent,  of  the  total  number  of  joint  cases 
in  children.  The  tubercle  may  be  deposited  in  the  syno- 
vial membrane,  or  rather  more  often  in  the  cancellous 
tissue  of  the  bones  themselves,  as  "  caries  sicca "  is  not 
unusual  in  the  head  of  the  humerus.  Suppuration  takes 
place,  and  the  abscess  tracks  downwards  along  the  biceps 
tendon,  or  opens  into  the  bursa  beneath  the  deltoid.  More 
rarely  it  appears  in  the  axilla,  or  it  may  point  behind  in 
the  supra-spinatus  or  infra-spinatus  fossa.  In  some  very 
interesting  cases,  known  as  caries  sicca,  the  disease  runs 
its  whole  course  without  marked  symptoms  and  without 
suppuration,  so  that  complete  bony  anchylosis  of  the 
shoulder  may  take  place  in  a  child  who  hardly  appears  to 


108      THE    SURGICAL    DISEASES    OF    CHILDREN 

have  been  ill.  A  similar  quiet  anchylosis  takes  place  in 
other  joints,  especially  in  the  elbow,  knee,  and  ankle. 
This  form  of  anchylosis  is  usually  attributed  to  tuberculous 
or  rheumatic  processes ;  but  we  are  quite  ignorant  of  its 
true  pathology,  and  it  requires  much  more  careful  observa- 
tion thau  has  yet  been  bestowed  upon  it. 

The  Symptoms  in  an  ordinary  case  of  tuberculous 
disease  of  the  shoulder  are  loss  of  function  in  the  joint, 
with  internal  rotation  and  adduction  of  the  arm.  Pain  is 
not  usually  a  very  marked  feature. 

The  Prognosis  is  good,  for  a  useful  limb  results  in  the 
majority  of  cases. 

Treatment. — Rest  is  best  obtained  by  the  application  of 
a  plaster-of-Paris  bandage,  after  a  pad  has  been  put  into 
the  axilla  to  produce  a  certain  amount  of  abduction.  An 
atypical  excision  may  sometimes  be  required  when  the 
sinuses  are  persistent,  but  such  an  operation  is  not  of  fre- 
quent occurrence.  A  formal  excision  of  the  joint  is  best 
performed  with  the  arm  extended  and  rotated  outwards, 
through  an  incision  carried  just  external  to  the  coracoid 
process  longitudinally  downwards,  so  as  to  expose  the  long 
head  of  the  biceps  lying  in  the  bicipital  groove.  The 
fibres  of  the  deltoid  are  held  back  by  broad  retractors, 
and  the  capsule  of  the  joint  is  laid  open.  Its  cavity  is 
thoroughly  explored,  and  the  diseased  tissue  is  removed  as 
far  as  may  be  necessary,  either  by  scraping  it  away  or  by 
sawing  through  the  head  of  the  bone,  either  at  the  anato- 
mical neck,  through  the  tuberosities,  or  at  the  surgical 
neck.  The  whole  of  the  diseased  tissue  is  removed  with 
dissecting  forceps  and  scissors,  the  cavity  of  the  joint  is 
swabbed  out  with  a  1  in  15  solution  of  zinc  chloride  and 
flushed,  and  the  sinuses  are  treated  in  a  similar  manner. 
The  parts  are  then  brought  together,  and  every  endeavour 
is  made  to  obtain  union  by  first  intention.    Passive  move- 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E   IO9 

ment  should  be  commenced  within  the  first  fortnight,  as  a 
movable  joint  is  required.  The  results  in  children  are 
not  so  good  as  in  adults. 

Elbow. 

Frequency. — Tuberculous  disease  of  the  elbow  is  very 
common,  as  it  forms  50  per  cent,  of  all  cases  of  joint 
disease  in  children.     It  nearly  always  begins  in  the  bones. 

Symptoms. — It  commences  insidiously,  for  the  pain  and 
functional  disturbance  are  not  marked  symptoms  until  the 
disease  is  well  advanced.  The  swelling  is  first  noticed  at 
the  back  of  the  joint,  but  it  soon  extends  all  round,  and  the 
typical  oval  tumour  is  developed,  which  has  led  to  the  use 
of  the  term  "  tumor  albus  "  as  a  synonym  for  tuberculous 
arthritis.  Pronation  and  supination  are  not  materially 
affected,  though  complete  extension  soon  becomes  impos- 
sible. Secondary  dislocations  are  rare,  but  anchylosis  is 
not  at  all  an  infrequent  result. 

Treatment. — Complete  rest  until  all  inflammatory  symp- 
toms have  passed  away  is  the  first  treatment  to  be  adopted 
in  these  cases.  The  elbow  should  be  bent  to  a  right  angle 
and  should  be  secured  in  a  plaster-of-Paris  case,  or  in  a  well- 
fitting  leather  splint  applied  along  the  back  of  the  joint. 
An  arthrectomy  must  be  performed  when  sinuses  form  in 
spite  of  this  treatment.  Mr.  Glutton  has  recently  advo- 
cated and  adopted  this  operation  with  great  success.  He 
prefers,  however,  to  do  it  quite  at  an  early  period,  and 
before  suppuration  has  taken  place  ;  for  he  aims  at  securing 
a  movable  joint  without  having  recourse  to  passive  move- 
ment.    His  method  of  operating  is  as  follows  : — 

Arthrectomy. — The  skin  is  thoroughly  cleansed  with 
soft  soap  or  liquor  potassse.  A  transverse  incision  is  made 
across  the  base  of  the  olecranon,  which  is  then  divided 
with  a  saw.     The  olecranon  is  drawn  upwards,  and  the 


HO     THE    SURGICAL    DISEASES    OF    CHILDREN 

fascial  expansion  is  divided  until  the  joint  can  be  so  freely 
opened  as  to  allow  all  its  parts  to  be  efficiently  scraped. 
All  the  granulation  tissue  is  then  removed  with  forceps 
and  scissors,  special  attention  being  paid  to  the  various 
pockets  in  the  synovial  membrane.  Pieces  of  loose 
cartilage  are  scraped  away  with  a  sharp  spoon,  and  the  soft 
and  carious  bone  is  gouged  out,  the  whole  of  the  exposed 
surface  being  repeatedly  flushed  with  a  solution  of  1  in  5000 
perchloride  of  mercury,  at  a  temperature  of  100°  F.  The 
most  difficult  part  of  the  operation  consists  in  clearing  the 
part  of  the  joint  beneath  the  brachialis  anticus. 

The  olecranon  is  attached  to  the  ulna,  by  means  of  a 
wire  or  an  aseptic  silk  suture,  as  soon  as  the  diseased 
tissues  have  been  removed.  The  edges  of  the  skin  incision 
are  brought  together  accurately  with  sutures,  and  an 
antiseptic  dressing  is  applied,  with  the  arm  at  a  right 
angle.  A  narrow  strip  of  plaster-of-Paris  bandage  is 
applied  to  the  front  of  the  arm,  and  in  favourable  cases 
the  dressings  are  not  removed  for  two  or  three  weeks. 
When  the  temperature  rises  the  wound  must  be  dressed, 
and  it  may  be  necessary  to  separate  its  edges  with  a 
director  to  allow  any  retained  secretion  to  escape.  The 
plaster-of-Paris  splint  is  applied  to  the  back  of  the  joint 
as  soon  as  the  wound  has  healed  ;  it  is  worn  until  all 
tenderness  has  disappeared— usually  for  two  or  three 
months— and  the  patient  is  then  allowed  to  use  the  arm 
freely.  In  many  cases  Mr.  Clutton  has  obtained  excellent 
results ;  in  some,  anchylosis  has  resulted ;  in  others,  the 
persistence  of  suppuration  has  obliged  him  to  have  re- 
course to  excision  of  the  joint. 

Excision. — A  formal  excision  is  best  performed  by 
rendering  the  arm  bloodless  with  an  Esmarch's  bandage, 
bending  the  elbow,  and  then  carrying  a  vertical  incision 
along  the  back  of  the  joint  and  a  little  to  the  inner  side 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E    I  I  I 

of  the  middle  of  the  olecranon.  The  incision  should  mea- 
sure three  inches  in  length,  and  the  anconeus  should  be 
injured  as  little  as  possible  in  order  to  secure  the  power 
of  extension.  Care  must  also  be  taken  to  injure  neither  the 
triceps,  its  aponeurosis,  nor  the  lateral  ligaments.  The 
condyles  of  the  humerus  are  cleaned,  and  the  bone  is  sawn 
through  on  a  level  with  their  base,  whilst  the  heads  of  the 
radius  and  ulna  are  made  to  project,  and  are  then  sawn  off 
together  above  the  attachment  of  the  brachialis  anticus. 
The  synovial  membrane  must  be  thoroughly  removed, 
especially  from  the  upper  part  of  the  olecranon  fossa,  where 
large  masses  of  granulation  tissue  are  apt  to  be  overlooked. 
The  wound  is  flushed,  closed  and  dressed  in  the  same 
manner  as  after  an  arthrectomy.  The  child  is  anaesthetised 
about  the  tenth  day,  and  gentle  passive  movements  of  the 
elbow  should  then  be  commenced.  They  must  be  repeated 
daily  by  the  surgeon,  who  fixes  the  arm  and  gently  pronates 
and  supinates  the  forearm. 

The  results  of  excision  of  the  elbow  are  satisfactory, 
though  it  is  not  often  necessary  to  perform  the  operation. 

Wrist. 

Tuberculous  disease  of  the  wrist  is  rare  in  young 
children,  but  it  becomes  a  little  more  frequent  as  age 
advances. 

Symptoms. — It  is  a  chronic  and  very  insidious  affection, 
usually  commencing  in  the  bones  themselves,  and  gene- 
rally involving  the  whole  of  the  carpus.  The  wrist  is  full 
and  smooth  in  outline  both  on  the  dorsal  and  palmar 
aspects.  There  is  a  little  difficulty  in  extending  it,  and 
the  hand  is  not  used  so  freely  as  its  fellow.  Sinuses  are 
formed  sooner  or  later,  and  if  these  be  probed  there  can  be 
no  doubt  as  to  the  presence  of  caseous  and  carious  bone. 
The  tendons  and  their  sheatl  s  are  often  involved  in  the 


112      THE    SURGICAL    DISEASES    OF    CHILDREN 

tuberculous  process.  I  have  occasionally  seen  cases  in 
which  the  carpal  bones  have  undergone  necrosis,  apparently 
due  to  the  disease  having  begun  as  a  tuberculous  synovitis  ; 
but  such  a  form  is  much  less  common  in  children  than 
tuberculous  caries  commencing  in  the  bones  themselves. 

Treatment. — The  treatment  in  the  early  cases  consists 
of  rest  both  of  the  wrist  and  hand.  Atypical  excision 
must  be  performed  in  the  later  stages,  and  as  much  of  the 
fungating  tissue  as  possible  should  be  removed  by  enlarg- 
ing the  sinuses.  A  free  application  of  zinc  chloride  should 
then  be  made.  The  results  are  not,  as  a  rule,  very  satis- 
factory ;  but  Mr.  Eve  recently  showed  a  case  in  which  the 
patient  could  play  the  piano  after  undergoing  an  excision 
of  the  wrist. 

Sacroiliac  Disease. 

Sacro-iliac  disease n  may  be  mistaken  for  tuberculous 
disease  of  the  hip  in  its  earlier  stages,  but  it  so  rare  in 
children  that  it  need  hardly  be  taken  into  account.  The 
affection  may  be  confined  to  the  sacro-iliac  joint,  or  it 
may  be  part  of  a  general  tuberculous  infection.  It  runs  a 
very  slow  course. 

Symptoms. — The  patient  limps,  and  the  pain  is  often 
much  more  severe  than  in  disease  of  the  hip.  The  buttock 
atrophies  early,  and  there  is  evidence  of  swelling  over  the 
joint.  The  pain  is  relieved  when  the  patient  is  in  bed, 
but  it  is  increased  by  movement,  by  pressing  the  iliac 
bones  inwards,  and  by  deep  pressure  over  the  joint. 
Abscesses  are  formed  which  pass  through  the  anterior 
ligament  and  open  beneath  the  glutseus  maximus  into  the 
psoas,  or  iliacus,  or  more  rarely  into  the  rectum.  They 
sometimes  track  along  the  multifidus  spinas,  and  point 
either  in  the  lumbar  region  or  directly  over  the  joint. 

Diagnosis  — The  movements  of  the  hip  are  free,  and  a 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E   I  I  3 

careful  examination  may  reveal  a  little  thickening  or 
swelling  over  the  affected  joint.  The  surgeon  should 
assure  himself  that  the  symptoms  are  not  due  to  tuber- 
culous disease  of  the  lumbar  spine. 

Prognosis. — The  prognosis  is  less  favourable  than  in 
hip  disease  or  lumbar  caries.  It  is  better  when  the 
posterior  part  of  the  articulation  is  affected  than  when  the 
carious  process  involves  the  front  of  the  joint,  for  it  then 
extends  to  the  sacrum,  and  leads  to  the  formation  of 
abscesses  within  the  pelvis. 

Treatment. — The  treatment  consists  in  keeping  the 
patient  absolutely  at  rest  in  bed,  with  a  weight  and  exten- 
sion apparatus  (p.  117)  upon  the  leg  of  the  affected  side, 
until  the  more  acute  symptoms  have  passed  off.  The  pain 
can  sometimes  be  relieved  by  the  application  of  a  Paquelin's 
cautery  over  the  affected  joint,  but  counter-irritation  must 
not  be  applied  when  abscesses  have  formed.  As  soon  as 
the  acute  symptoms  have  subsided,  the  patient  should  be 
allowed  to  go  into  the  fresh  air,  after  a  double  Thomas' 
splint  has  been  applied  ;  but  every  night  the  splint  should 
be  taken  off  and  the  extension  reapplied.  The  splint 
reaches  from  the  axilla  to  just  above  the  knee,  and  is  pro- 
vided with  a  broad  band  passing  round  the  body  at  the 
level  of  the  sacro-iliac  joint.  It  should  have  shoulder 
straps.  A  leather  splint  moulded  to  the  pelvis  may  be 
employed  in  place  of  the  Thomas'  ;  but  in  either  case  a 
boot  and  patten  should  be  put  upon  the  sound  leg,  and 
crutches  should  be  used. 

Operative  measures  must  be  adopted  as  soon  as  there  is 
evidence  of  suppuration. 

Hip. 

Frequency. — Tuberculous  disease  of  the  hip  is  said  to 
form   37   per  cent,   of   all  the  cases  of    joint  disease  in 

1 


I  14      THE    SURGICAL    DISEASES    OF    CHILDREN 

children.  Riedel  has  recently  shown  that  84  per  cent,  of 
the  cases  begin  in  the  bone,  and  that  only  16  per  cent,  are 
synovial  in  origin. 

Course. — Sequestra  are  much  more  common  in  cases  of 
hip  disease  than  in  any  other  joint.  The  infection  is 
usually  mixed  so  that  cold  abscesses  are  formed  early,  the 
capsule  of  the  joint  is  destroyed,  and  displacement  of  the 
head  of  the  femur  is  frequent,  though  true  dislocation  is 
rare  (see  p.  120).  Remarkable  trophic  disturbances  are 
seen  in  connection  with  the  large  muscles  of  the  gluteal 
region.  The  exact  cause  of  their  wasting  is  a  matter  of 
dispute,  though  there  is  reason  to  suppose  that  it  may  be 
reflex  in  origin  and  that  it  is  not  due  simply  to  disease  or 
to  flexion  of  the  thigh. 

Symptoms. — The  symptoms,  as  in  other  cases  of  tuber- 
culous arthritis,  are  ill-defined  in  the  early  stages.  The 
first  noticeable  symptom  is  limping,  either  with  or  without 
pain.  The  limping  is  due  to  the  abduction  of  the  thigh, 
external  rotation,  and  to  the  flexion  in  which  it  is  main- 
tained by  the  tonic  contraction  of  the  surrounding  muscles  ; 
for  if  the  child  be  ansesthetised  during  this  stage  the 
movements  at  the  hip  are  found  to  be  quite  free.  Pain 
felt  either  in  the  knee,  or  referred  to  the  hip,  with  or  with- 
out exacerbations  at  night,  is  a  frequent  symptom  at  this 
stage.  The  pain  is  usually,  and  I  think  correctly,  assumed 
to  be  due  to  stimulation  of  one  of  the  articular  twigs  of 
the  obturator  nerve,  running  along  the  ligamentum  teres  ; 
but  some  surgeons  hold  that  it  is  an  impression  conducted 
along  the  centre  of  the  bone  from  the  inflamed  medulla. 

The  flexed  and  abducted  position  of  the  limb  leads  to 
certain  compensatory  changes  to  enable  the  patient  to 
maintain  his  equilibrium.  Lordosis  and  some  amount  of 
lateral  curvature  are  the  most  marked,  and  as  a  result  of 
these  changes  the  limb  on  the  affected  side  seems  to  be 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS^   I  I  5 

longer  than  it  is  upon  the  sound  side,  so  long  as  it  is  kept 
in  a  state  of  abduction,  though  if  it  be  adducted  it  seems 
to  be  shorter.  It  is  important,  therefore,  actually  to  mea- 
sure an  affected  limb,  to  ascertain  that  lengthening  or 
shortening  does  not  really  exist,  or  else  to  observe  that  the 
two  anterior  superior  spines  of  the  ilium  are  not  upon  the 
same  level.  Swelling  in  the  neighbourhood  of  the  joint  is 
an  early  symptom  of  the  disease.  It  is  often  most  obvious 
behind  the  greater  trochanter,  or  it  may  be  noticed  that 
the  pulsation  in  the  femoral  artery  is  more  superficial  and 
easier  to  feel  in  the  groin  on  the  affected  side.  A  rectal 
examination,  in  some  obscure  cases  where  the  disease  has 
begun  in  the  acetabulum,  may  reveal  the  presence  of  a 
painful  swelling  in  the  affected  ilium. 

Differential  Diagnosis. — The  recognition  of  hip  disease 
is  not  always  easy,  for  it  has  to  be  distinguished  from 
hysteria,  from  spinal  caries,  from  simple  neuralgia  of  the 
joint,  as  well  as  from  sacro-iliac  disease. 

Hysterical  disease  of  the  hip  usually  comes  on  suddenly 
after  a  slight  injury.  It  lasts  for  very  long  periods  of 
time  without  producing  any  of  the  objective  symptoms 
characterising  active  disease.  The  pain  is  more  violent 
than  in  tuberculous  disease,  and  it  may  be  elicited  by  light 
cutaneous  stimuli,  which  would  be  quite  ineffectual  in  true 
disease.  The  hysterical  symptoms  may  cease  as  abruptly 
as  they  commenced.  Osteomyelitis  of  the  femur  or  aceta- 
bulum runs  a  more  rapid  course  than  tuberculous  disease ; 
but  all  infective  forms  of  inflammation,  as  well  as  that 
which  is  due  to  syphilis,  have  to  be  taken  into  account  in 
making  a  diagnosis. 

Treatment.  —  Rest  and  extension  will  often  cure  a 
patient  in  the  earlier  stages  of  the  disease,  even  when 
some  amount  of  suppuration  lias  takeu  place.  Dr.  Sayre 
says  that  patients  who  have  been  perfectly  cured  of  hip 


Il6      THE    SURGICAL    DISEASES    OF    CHILDREN 

disease  should  be  able  to  flex  the  thigh  to  an  acute  angle, 
and  cross  the  foot  over  the  opposite  thigh.  The  crossing 
of  the  foot  he  considers  a  crucial  test,  for  it  is  a  very  diffi- 
cult movement  for  a  patient  to  execute  if  there  is  the  least 
rigidity  about  the  hip-joint.  He  says  that  if  an  imperfectly 
cured  patient  be  watched  as  he  puts  on  his  boots  and  laces 
them,  he  will  nearly  always  stand  and  put  his  foot  out  to 
one  side  ;  whilst  a  person  who  has  perfect  freedom  of  move- 
ment at  his  hip,  sits  and  crosses  his  foot  over  the  opposite 
thigh. 

Treatment  by  Extension.— The  method  of  applying 
extension  is  shown  in  fig.  15.     It  is  as  follows  :— The  leg  is 
carefully  washed  and  thoroughly  dried.     A  piece  of  stout 
strapping,  2  inches  in  width  and  28,  32,  or  36  inches  in 
length,  is  obtained  and  doubled ;  into  its  centre  is  secured 
a  square  piece  of  wood  called  the  stirrup.     The  strapping 
is  warmed,  and  applied  to  either  side  of  the  leg,  care  being 
taken  that  it  extends  an  inch  or  two  above  the  knee  (fig. 
15b).     The  two  longitudinal  pieces  of  strapping  are  kept 
in  place  by  winding  a  second  piece  of  strapping  over  them 
and  spirally  up  the  leg.    A  light  roller  bandage,  not  shown 
in  the  figure,  is  placed  over  the  strapping  to  keep  it  secure. 
A  cord  is  then  passed  through  the  centre  of  the  stirrup 
and  is  allowed  to  run  over  a  pulley  fixed  to  the  bed,  a 
weight  of  varying  amount  being  attached  to  the  end  of 
the  cord.     This  weight  should  be  sufficient  to  overcome 
the  starting  pains  at  night  in  an  ordinary  case,  and  the 
limb  must  be  extended  at  first  in  its  faulty  axis.     It  is 
usually  two  pounds  for  a  child  of  two  years  old,  and  in- 
creases half  a  pound  for  each  additional  year.      The  foot 
of  the  bed  may  be  raised   upon  two  wooden  blocks  three 
or  four  inches  in  height.     The  cot  is  provided  with  a  firm 
mattress,  and   the  child  is  prevented  from  raising  itself 
into  a  sitting  position  by  a  band  of  webbing,  provided  with 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.*:    I  I  J 


loops  to  pass  round  its  shoulders  (fig.  15  d),  the  ends  being 
secured  under  the  bed  (fig.  15  E).      It  is  often  necessary  to 


Il8      THE    SURGICAL    DISEASES    OF    CHILDREN 

keep  the  pelvis  level  in  a  restless  child  by  applying  a  long 
Liston's  splint  upon  the  sound  side.  The  extension  must  be 
capable  of  alterations  in  height  and  in  angle  to  enable  the 
lordosis  to  be  entirely  overcome,  and  it  should  be  a  routine 
part  of  the  surgeon's  business  to  pass  his  hand  under  the 
lumbar  spine  of  the  patient,  as  often  as  he  sees  him,  to 
assure  himself  that  it  is  flat  (fig.  15  c)  upon  the  bed.  The 
lordosis,  which  is  at  first  extensive,  can  nearly  always  be 
overcome  by  continued  extension,  the  hip  being  at  first 
flexed  to  the  full  extent  necessary  to  overcome  the  lumbar 
arch  by  the  use  of  a  graduated  series  of  wedge  -  shaped 
pillows  under  the  leg  (fig.  15  a).  The  pulley  should  then 
be  lowered  daily,  and  gradually,  until  the  two  legs  are 
absolutely  parallel. 

The  amount  of  lordosis  is  of  great  importance  in  the 
treatment  of  hip  disease  by  extension,  for  it  is  a  measure 
of  the  flexion  of  the  hip  ;  but  it  is  too  often  overlooked  in 
a  patient  who  has  been  confined  to  his  bed  for  a  long  time, 
and  the  surgeon  should  therefore  constantly  assure  himself 
that  it  does  not  exist,  by  passing  his  hand  from  time  to 
time  under  the  loins,  and  ascertaining  that  the  body  lies 
flat  upon  the  bed.  The  leg  must  be  raised  if  the  loin  is 
arched ;  but  when  anchylosis  is  unavoidable,  a  slight 
amount  of  flexion  at  the  hip  may  render  the  limb  more 
serviceable  than  one  which  is  absolutely  straight.  It  is 
very  important,  too,  in  cases  treated  by  prolonged  rest 
with  extension,  that  the  limb  should  not  be  allowed  to 
become  adducted. 

The  treatment  by  weight  extension  must  be  maintained 
for  many  weeks  or  months,  until  all  symptoms  of  muscular 
rigidity  have  passed  away,  and  until  the  joint  has 
resumed  its  original  freedom  of  movement.  This  takes 
place  in  a  certain  proportion  of  cases,  and  the  result  of 
the  treatment  is  then  perfect. 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E    I  1 9 

Symptoms  and  Treatment  of  Abscesses.  —  Ab- 
scesses form  in  a  large  number  of  cases,  even  though  the 
joint  has  been  maintained  at  absolute  rest,  and  this  must 
of  necessity  take  place  in  all  cases  where  there  is  a  mixed 
infection.  The  abscess  is  usually  deeply  situated  near  the 
joint,  and  it  often  requires  great  skill  to  detect  its  pre- 
sence at  an  early  period,  for  the  sense  of  deep  fluctuation 
is  often  very  obscure.  An  increase  in  "  night  screaming  " 
when  the  pain  is  not  relieved  by  increasing  the  weight  of 
the  extending  force,  is  often  one  of  the  earliest  symptoms  of 
the  formation  of  such  an  abscess.  The  pain  in  these  cases 
is  sometimes  relieved  by  the  administration  of  five-grain 
doses  of  sodium,  or  potassium  bromide,  with  the  local  appli- 
cation of  hot  fomentations  of  boric  acid  or  of  belladonna. 

All  abscesses  must  be  opened  and  rendered  aseptic 
as  soon  as  they  are  recognised  ;  sequestra  should  be  re- 
moved, and  if  they  cannot  be  made  to  heal  by  first  inten- 
tion they  must  be  drained.  The  abscesses  usually  point 
either  in  Scarpa's  triangle ;  on  the  inner  side  of  the  thigh  ; 
below  the  anterior  superior  spine,  between  the  tensor 
fasciae  femoris  and  the  sartorius  ;  just  above  the  insertion 
of  the  psoas  muscle,  or  beneath  the  glutei  behind.  In 
some  cases  they  pass  into  the  pelvis  and  may  open  above 
Poupart's  ligament,  or  they  may  even  open  into  the  rectum 
or  bladder.  They  should  never  be  allowed  to  attain  any 
large  size,  or  to  open  spontaneously,  as  they  infect  the 
various  tissues  with  which  they  come  into  contact.  Their 
contents  vary  greatly,  from  ordinary  pus  to  a  mass  of 
mortar-like  material,  consisting  of  caseating  products  of 
the  tuberculous  inflammation. 

Sequelae. — Displacement  of  the  femur  upwards  occurs 
in  neglected  cases,  and  sometimes  in  spite  of  every  care. 
The  leg  then  becomes  shortened,  inverted,  and  the  tro- 
chanter on  the  affected  side  is  placed  above  Nelaton's  line. 


120      THE    SURGICAL    DISEASES    OF    CHILDREN 

The  shortening  is  partly  dne  to  a  change  in  position  of  the 
head,  and  partly  due  to  trophic  changes  in  the  bone  itself. 
A  true  dislocation  sometimes  takes  place  suddenly  and 
quite  early  in  the  disease,  but  the  displacement  is  more 
usually  gradual,  and  is  the  result  of  the  absorption  of  the 
head  of  the  femur,  and  the  enlargement  of  the  acetabulum 
upwards  and  backwards.  Mr.  Holmes  has  shown  that 
true  dislocation,  in  which  the  head  of  the  femur  leaves  the 
acetabulum,  is  a  rare  result  of  hip  disease,  and  that  the 
ordinary  appearances  are  due  to  the  head  of  the  bone  being 
drawn  upwards  by  muscular  action  so  as  to  bring  the 
trochanter  into  a  relatively  higher  position.  The  integrity 
or  destruction  of  the  capsule  will  determine  the  exact 
position  of  the  bone. 

The  displacement  is  disastrous,  on  account  of  the 
shortening  which  it  produces,  and  it  must  be  prevented 
as  far  as  possible  by  careful  extension,  so  that  when 
anchylosis  takes  place  the  upper  end  of  the  femur  may 
still  bear  a  direct  relation  to  the  lower  part  of  the  altered 
acetabulum.  The  tendency  to  inversion  and  adduction  of 
the  thigh  must  also  be  overcome.  Anchylosis  in  a  good 
position  is  the  best  that  can  be  hoped  for  in  these 
cases ;  but  perfect  movement  in  the  hip  may  be  obtained 
after  the  formation  of  abscesses,  and  even  when  sinuses 
have  remained  open  for  some  time. 

Duration. — The  affection  usually  takes  months  or  years 
to  run  its  course,  but  in  a  minority  of  cases  the  disease  is 
acute,  dislocation  takes  place  early,  there  is  very  great 
pain,  and  death  takes  place  from  some  other  tuberculous 
lesion  ;  in  fact,  the  disease  of  the  hip  is  only  part  of  a 
general  tuberculosis. 

Treatment.  (1)  Palliative. — The  treatment  in  the 
chronic  forms  is  to  keep  the  patient  in  a  horizontal  position 
until  the  muscular  rigidity  has  become  markedly  lessened,  or 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E    12  1 

until  abscesses  are  no  longer  formed,  and  there  is  evidence 
that  firm  anchylosis  has  taken  place.  He  is  then  ordered 
to  wear  a  Thomas'  hip-splint,  a  patten  is  put  upon  the 
boot  of  the  sound  leg,  and  he  is  taught  to  walk  upon 
crutches  until  all  symptoms  of  disease  have  passed  away. 
He  should  be  examined,  however,  from  time  to  time  to  see 
that  the  disease  is  quiescent.  As  soon  as  the  disease  is 
cured,  the  patient  is  provided  with  a  boot  whose  sole  is 
thick  enough  to  make  up  for  the  shortening  of  the  affected 
leg ;  or,  when  it  is  important  to  conceal  the  deformity  as 
much  as  possible,  an  O'Connor  extension  apparatus  may 
be  employed  on  great  occasions,  for  its  permanent  use  is 
inadvisable.  It  is  surprising  to  notice  how  little  discom- 
fort is  experienced  by  a  young  patient,  even  when  one 
hip  is  completely  anchylosed. 

(2)  Operative  Treatment :  Primary. — Excision  of  the 
hip  is  performed  when  the  disease  progresses  in  spite  of 
adequate  treatment  by  rest,  when  sequestra  are  present 
within  the  capsule,  and  when  there  is  reason  to  suppose  that 
the  head  of  the  bone  is  dead,  though  this  is  more  often  the 
result  of  acute  osteomyelitis  than  of  tuberculous  disease. 
The  operation  is  generally  done  somewhat  earlier  than  in 
similar  disease  of  other  joints ;  and,  ideally,  it  should  be 
performed  whilst  the  disease  is  confined  to  the  joint,  and 
has  not  yet  invaded  the  surrounding  parts.  It  has  the 
great  disadvantage  that  the  upper  epiphysis  of  the 
femur  lies  within  the  capsule  of  the  joint,  and  must 
therefore  be  removed,  so  that  shortening  of  necessity 
follows  the  operation. 

The  patient  is  prepared  in  the  usual  manner  for  excision 
of  a  joint,  and  any  large  abscesses  having  been  thoroughly 
scraped  and  cleansed,  an  incision  is  carried  downwards 
and  a  little  inwards,  commencing  just  below  the  anterior 
superior  spine  of  the  ilium,  and  terminating  three  inches 


122      THE    SURGICAL    DISEASES    OF    CHILDREN 

lower  down,  so  that  it  passes  between  the  tensor  fasciae 
femoris  on  the  outer  side,  and  the  outer  border  of  the 
sartorius  upon  the  inner  side.  This  incision  is  carried 
straight  down  to  the  bone,  and  in  many  cases  it  will  be 
found  possible  to  utilise  the  sinus  communicating  with  the 
abscess,  which  usually  lies  beneath  the  sartorius  and  the 
tensor  fasciae  femoris,  to  enable  the  surgeon  to  reach  the 
joint.  The  soft  parts  are  retracted,  and  a  finger  is  intro- 
duced to  feel  the  capsule  and  to  ascertain  the  condition  of  the 
joint.  Sequestra  are  removed  with  forceps,  or  if  the  head  is 
so  carious  and  ulcerated  that  it  be  deemed  unwise  to  leave  it, 
the  great  trochanter  is  sawn  through  obliquely  downwards 
and  forwards  with  a  narrow-bladed  saw,  and  it  is  removed. 
Mr.  Pollard  prefers  to  saw  through  the  neck  of  the  bone 
only,  and  he  takes  care  not  to  divide  more  of  the  Y-ligament 
than  is  absolutely  necessary ;  for  it  is  one  of  the  chief 
agents  in  limiting  the  subsequent  displacement  of  the  femur 
upwards.  It  is  sometimes  even  necessary  to  saw  through 
the  femur  below  the  trochanter  ;  but  this  is  only  done  in 
cases  of  very  extensive  disease  of  the  neck  of  the  femur. 

After  the  head  of  the  bone  has  been  removed,  the 
acetabulum  is  carefully  examined  with  the  finger  to  ascer- 
tain what  carious  patches  it  may  contain ;  and  these,  with 
as  much  of  the  fungating  tissue  as  can  be  reached,  are 
removed  with  a  flushing  scoop.  The  cavity  is  then 
swabbed  out  with  a  solution  of  zinc  chloride,  thoroughly 
irrigated  with  sterilised  water  at  the  temperature  of  the 
body,  dried,  and  as  soon  as  the  bleeding  has  been  com- 
pletely arrested,  the  wound  is  sewn  up  without  any 
drainage-tube.  Antiseptic  dressings  are  applied,  and 
the  requisite  rigidity  of  the  joint  is  obtained  by  means 
of  a  plaster-of-Paris  case,  shaped  like  a  pair  of  women's 
drawers,  or  by  a  double  Thomas'  splint,  so  modified  as  to 
maintain  the  limb  in  slight  abduction. 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E   I  23 

Mr.  Barker,  who  has  done  much  to  perfect  the  technique 
of  the  operation  in  England,  points  out  that  the  best  re- 
sults are  obtained  when  union  occurs  by  first  intention, 
and  this  can  only  be  ensured  when  the  operation  is 
performed  before  the  sinuses  have  formed.  If,  however, 
sinuses  are  present  at  the  time  of  the  operation,  they  must 
be  thoroughly  scraped  and  rendered  as  aseptic  as  possible. 
They  may  sometimes  be  utilised  as  the  lines  of  incision 
when  they  are  of  considerable  size. 

The  hip  does  not  lend  itself  readily  to  arthrectomy;  but 
atypical  operations,  or  operations  which  are  not  carried 
out  upon  the  formal  lines  described  in  text-books,  are 
often  necessary.  These  operations  are  performed  to  re- 
lieve symptoms  as  they  arise,  by  removing  such  sequestra 
and  pieces  of  diseased  bone  or  tissue  as  may  from  time  to 
time  be  discovered.  Secondary  operations  are  required 
nearly  as  often  after  excision  of  the  hip  as  after  excision 
of  the  knee.  Indeed,  it  very  rarely  happens  in  either 
joint  that  a  single  operation  is  sufficient  to  secure  the 
absolute  removal  of  all  the  diseased  tissue. 

Secondary  Operations.  —  Operative  measures  are  re- 
quired when  anchylosis  of  the  hip  has  taken  place  in  a 
faulty  position.  Flexion  and  adduction  of  the  joint  lead 
to  the  most  serious  interference  with  its  functions.  Teno- 
tomy and  myotomy  must  be  performed  if  the  contraction 
be  of  muscular  origin.  The  sartorius,  tensor  fasciae  feino- 
ris,  glutseus  medius,  rectus  and  ilio-psoas  muscles  most 
often  require  division.  The  adductors,  too,  may  be  divided, 
taking  care  not  to  injure  the  femoral  vessels. 

Forcible  straightening  under  an  anaesthetic,  after  all  the 
active  symptoms  of  the  disease  have  passed  away,  is  suf- 
ficient to  overcome  a  fibrous  anchylosis ;  but  the  method 
must  be  used  with  care,  as  great  and  permanent  injury 
may  be  done  to  the  joint. 


124      THE    SURGICAL    DISEASES    OF    CHILDREN 

A  sub-trochanteric  osteotomy  must  be  performed  when 
there  is  bony  anchylosis.  An  incision  is  made  just  below 
the  great  trochanter,  and  upon  its  outer  aspect.  An 
Adams'  saw  is  passed  along  the  knife,  which  is  then  with- 
drawn, and  the  bone  is  sawn  from  without  inwards  until 
its  division  can  be  completed  by  fracturing  the  compact 
tissue  on  its  inner  aspect.  The  section  must  be  made  at 
right  angles  to  the  long  axis  of  the  femur,  and  without 
any  reference  to  the  pelvis.  It  is  generally  necessary  to 
divide  some  of  the  tendons  surrounding  the  hip  before  the 
joint  can  be  completely  straightened.  The  wounds  are 
dressed  antiseptically,  and  heal  by  first  intention.  The 
limb  is  put  up  in  its  corrected  position,  and  a  long  Liston's 
splint  or  plaster-of-Paris  drawers  are  applied  for  a  month, 
care  being  taken  during  the  whole  time  that  the  leg  and 
thigh  are  maintained  in  slight  abduction. 

Amputation  at  the  hip-joint  still  has  to  be  performed 
occasionally  to  save  the  life  of  a  patient  suffering  from 
morbus  coxae.  It  is  required  when  excision  has  failed  ; 
when  profuse  suppuration  threatens  life  ;  when  lardaceous 
disease  manifests  itself  in  the  form  of  diarrhoea  and 
albuminuria  ;  when  there  is  evidence  of  progressive  tuber- 
culous disease  in  other  organs  ;  in  some  very  acute  cases, 
attended  with  extreme  pain,  and  when  there  is  evidence 
that  the  disease  has  extended  from  the  acetabulum  into 
the  pelvis. 

The  thigh  is  readily  and  almost  bloodlessly  removed  by 
Furneaux-Jordan's  method.  A  simple  circular  incision  is 
made  down  to  the  bone  at  the  apex  of  Scarpa's  triangle 
(digital  compression  of  the  femoral  artery  being  made  by 
an  assistant),  the  femur  is  sawn  through,  and  the  main 
arteries  are  picked  up  and  tied  as  quickly  as  possible. 
A  straight  incision  down  to  the  bone  is  then  made  along 
the  outer  side  of  the  thigh,  commencing  at  the  top  of  the 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS^l   I  25 

great  trochanter,  and  terminating  at  the  cut  end  of  the 
stump.  The  soft  tissues,  including  the  periosteum,  are  then 
stripped  off  the  femur,  and  the  head  of  the  bone  is  disar- 
ticulated. This  part  of  the  operation  is  perfectly  easy  in 
a  child,  for  the  softened  tissues  are  easily  stripped  off,  and 
the  head  of  the  bone  has  often  disappeared,  either  wholly 
or  in  part.  The  periosteum,  acetabulum,  and  the  sinuses 
are  examined,  if  the  condition  of  the  patient  permits,  and 
all  the  granulation  tissue  is  removed  with  a  sharp  spoon. 
The  muscles  retract  so  much  into  the  acetabulum  that  it 
is  unnecessary  to  form  any  skin-flap,  for  the  edges  of  the 
wound  come  together  nicely.  A  drainage-tube  is  inserted, 
sutures  are  introduced,  and  a  good  sound  stump  usually 
results.  When  it  is  important  to  lose  as  little  blood  as 
possible,  the  outer  incision  should  be  made  first,  the  head 
of  the  femur  disarticulated,  the  soft  parts  freed  from  the 
bone ;  the  circular  incision  dividing  the  femoral  artery 
then  completes  the  operation. 

Double  Disease  of  the  Hip. 

Tuberculous  disease  of  both  hips  is  not  of  very  frequent 
occurrence.  Dr.  Ridlon,  who  has  had  opportunities  of 
observing  such  cases,  says  that  it  rarely  begins  simul- 
taneously in  both  joints.  The  second  hip  may  become 
affected  whilst  the  patient  is  confined  to  bed,  so  that  it  is 
clearly  not  due  to  injury.  The  joint  first  affected  is  often 
the  last  to  recover,  so  that  the  disease  runs  a  more  rapid 
course  in  the  joint  secondarily  affected. 

Treatment.— The  treatment  does  not  differ  from  that  of 
the  ordinary  form  of  morbus  coxae.  The  patient  is  put  to 
bed  with  a  weight  and  extension  until  the  acute  symptoms 
have  passed  away.  He  is  then  allowed  to  go  about  in  a 
well-fitting  double  Thomas'  splint.  The  result  is  not  un- 
favourable ;  complete  recovery  may  take  place,  but  double 


126      THE    SURGICAL    DISEASES    OF    CHILDREN 

anchylosis,  with  more  or  less  adduction,  is  the  commoner 
result. 

Knee. 

Frequency.— Tuberculous  disease  of  the  knee  ranks 
next  in  frequency  to  morbus  coxse,  for  it  occurs  in  307  per 
cent,  of  all  the  joint  diseases  in  children. 

Pathology. — The  disease  commences  more  frequently  as 
a  synovitis  than  in  other  cases,  though  foci  of  inflamma- 
tion in  the  bone  are  by  no  means  uncommon,  either  in  the 
ends  of  the  bone,  within  the  capsule  of  the  joint,  or  in 
those  parts  which  are  extra-articular.  The  tuberculous 
synovitis  assumes  two  forms  in  the  knee — one,  a  simple 
and  chronic  form  leading  to  hydrops  articuli,  which  is 
rare,  and  the  other  a  fungating  variety,  which  is  common. 
The  infiltration  usually  begins  at  the  point  where  the 
synovial  membrane  blends  with  the  periosteum,  or  with 
the  articular  cartilage.  The  synovial  membrane  and  its 
fringes  become  thickened,  and  the  inflammatory  products 
either  caseate  or  suppurate.  Large  abscesses  are  thus 
formed  in  the  joint,  or  its  cavity  may  be  so  much  obliter- 
ated by  the  tuberculous  thickening  as  to  allow  of  the 
formation  of  local  abscesses.  When  the  bones  are  pri- 
marily involved,  and  in  very  chronic  cases,  radical  changes 
take  place  in  the  condyles  of  the  femur  and  in  the  head  of 
the  tibia.  Flexion  results  with  backward  displacement 
and  external  rotation  of  the  tibia,  giving  rise  to  the 
characteristic  "  triple  displacement." 

Symptoms. — The  disease  commences  in  children  between 
three  and  six  years  of  age,  though  I  have  under  my  care 
at  the  present  time  a  well-marked  case  of  white  swelling 
of  the  knee  in  a  child  aged  eleven  months.  It  is  usually 
attributed  to  an  injury.  The  child  limps,  because  his  knee 
is  bent ;  but  he  does  not,  as  a  rule,  complain  of  pain  in 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.£   12J 

the  earlier  stages.  Examination  shows  that  the  joint  is 
warmer  than  its  fellow,  and  than  the  limb  above  and 
below  it.  The  outlines  of  the  joint,  especially  npon  either 
side  of  the  ligamentum  patellse,  are  fuller  than  they  should 
be,  so  that  there  is  a  diminution  in  the  natural  dimples. 
The  limb  above  and  below  the  joint  is  wasted.  There  is 
some  fluctuation  in  the  joint,  but  not  much.  In  cases  of 
hydrops  articuli,  however,  fluid  collects  in  the  joint  in 
considerable  quantities,  but  its  functions  are  hardly  inter- 
fered with  for  years.  In  the  ordinary  pulpy  degeneration 
of  the  synovial  membrane,  the  outline  of  the  knee  soon 
becomes  oval,  and  all  evidence  of  the  thickened  synovial 
membrane  is  lost  to  sight,  owing  to  the  (edematous  con- 
dition of  the  peri-articular  connective  tissues,  though  the 
increased  resistance  which  it  offers  can  still  be  felt. 
Anchylosis,  with  the  limb  in  a  state  of  triple  displace- 
ment— flexion,  external  rotation  and  backward  displace- 
ment of  the  tibia — takes  place  in  simple  infection,  as  well 
as  when  the  joint  has  suppurated. 

Diagnosis. — Tuberculous  disease  of  the  knee  may  be 
mistaken  for  rheumatic  or  syphilitic  arthritis,  or  for  osteo- 
myelitis ;  and,  conversely,  an  ossifying  sarcoma  of  the  lower 
end  of  the  femur  may  be  mistaken  for  a  case  of  tuberculous 
disease,  though  the  infiltration  of  the  glands  in  the  groin 
will  soon  render  the  true  nature  of  the  case  conspicuous. 
Gonorrhoeal  arthritis  also  occurs  in  children,  but  it  is  very 
rare,  and  there  is  evidence  of  a  purulent  discharge  either 
from  the  eyes  or  the  genitals. 

Treatment.  (1)  Palliative. — The  treatment  of  tuber- 
culous inflammation  of  the  knee  consists  in  keeping  the 
joint  extended  and  at  rest,  indications  which  are  best 
met  by  the  application  of  a  plaster-of-Paris  case,  by  a 
Thomas'  knee-splint,  or  by  a  properly  moulded  leather 
splint.      Thomas'  splint  (fig.  16),   with  extension,  is  ap- 


128      THE    SURGICAL    DISEASES    OF    CHILDREN 

plied  in  the  following  manner  : — A  splint  is  selected  which 
reaches  from  the  groin  to  four  inches  below  the  instep. 
The  oblique  ring  at  the  top  of  the  splint  is  slipped  up  the 
thigh  until  it  lies  comfortably  in  the  groin,  the  child  being 
recumbent.  An  extension  apparatus,  similar  to  that  used 
in  the  treatment  of  hip  disease,  is  then  applied  to  the  leg. 
Four  strips  of  strapping,  two  inches  wide,  and  long  enough 
to  go  twice  round  the  thickest  part  of  the  limb,  are  then 


Fig.  16.— Back  view  of  a  boy  wearing  a  Thomas'  knee-splint  applied  in  the 
manner  described  in  the  text. 

cut — two  for  the  thigh,  and  two  for  the  leg.  One  end  of 
the  first  piece  of  strapping  is  secured  round  the  upper  part 
of  the  thigh,  and  is  passed  from  without  inwards  round  the 
outside  of  the  splint.  The  second  strip  is  secured  round 
the  lower  part  of  the  thigh  in  an  opposite  direction,  for  it 
is  passed  round  the  borders  of  the  splint  from  within  out- 
wards,  so  that  the  thigh  is  slung  and  fixed  immovably 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E    I  29 

between  the  two  parallel  borders  of  the  splint.  The 
thigh  being  fixed,  the  knee  is  straightened,  and  the  ex- 
tension is  maintained  by  tying  tapes  from  the  stirrup 
to  either  side  of  the  splint  below  the  cross-bar.  The  leg 
is  then  fixed  in  a  manner  similar  to  the  thigh,  by  passing 
two  strips  of  strapping  in  opposite  directions.  A  roller 
bandage — not  shown  in  the  figure — is  finally  applied  from 
the  foot,  which  should  be  kept  at  right  angles,  as  high 
as  the  middle  of  the  thigh.  The  patient  is  then  provided 
with  a  patten  for  the  sound  foot,  and  is  allowed  to  go 
about  upon  crutches.  Anchylosis  with  the  knee  straight 
may  sometimes  be  obtained  by  these  means. 

(2)  Operative  Treatment. — In  cases  of  hydrops  articuli, 
the  synovial  fluid  may  be  let  out  and  the  operation  of 
sclerogeny  (p.  102)  may  be  performed  ;  or  a  drachm  or 
two  of  camphorated  napb.tb.ol  may  be  introduced  through 
the  aspirating  syringe,  the  joint  being  afterwards  kept  at 
rest.  Radical  measures  must  be  adopted,  and  either  arth- 
rectomy  or  excision  must  be  performed  when  suppuration 
has  taken  place,  and  simple  incision  and  drainage  have 
failed  to  cure ;  for  it  is  important  in  these  cases  to  secure 
bony  anchylosis  of  the  joint  as  rapidly  as  possible. 

Arthrectomy  or  Erasion  of  joints  is  a  term  which  has 
been  adopted  to  denote  the  operation  of  removing  all  the 
diseased  structures  from  a  tuberculous  joint.  It  is  em- 
ployed for  those  cases  in  which  the  stress  of  the  disease 
has  fallen  upon  the  synovial  membranes,  and  in  the  extra- 
articular forms  of  disease,  the  bones  and  epiphyses  being 
only  slightly  affected.  Its  success  depends,  to  a  very  large 
extent,  upon  minute  attention  to  details.  It  should  be  the 
aim  of  the  surgeon  to  remove  every  particle  of  diseased 
t  issue — though,  scientifically,  this  is  not  an  absolute  neces- 
sity, for  we  know  that  here,  as  in  other  tuberculous 
lesions,  if  the  bulk  of  the  disease  be  removed,  the  innam- 

K 


130      THE    SURGICAL    DISEASES    OF    CHILDREN 

matory  processes  thereby  set  up  are  able  to  destroy  the 
slight  manifestations  of  tubercle. 

The  operation  was  introduced  into  this  country  by  Mr. 
Wright,  of  Manchester,  in  1881,  and  its  adoption  has  been 
ably  advocated  by  Mr.  Edmund  Owen  and  by  Mr.  Clutton. 
The  operation  is  specially  adapted  for  the  knee,  and  in  a 
less  degree  for  the  ankle.  It  has  the  great  advantage  over 
excision,  that  in  its  most  successful  form  it  leaves  a  joint 
the  movements  of  which  are  but  little  if  at  all  impaired, 
whilst  the  limb  is  in  no  degree  shortened.  Its  great  dis- 
advantages lie  in  the  frequent  relapses,  necessitating  re- 
peated operations,  and  in  the  very  prolonged  convalescence. 
When  the  operation  fails  completely,  the  extensive  sup- 
puration militates  against  the  more  radical  measures  of 
excision  or  amputation  which  have  then  to  be  adopted. 

The  operation  should  be  performed  quite  at  an  early 
stage  of  the  disease,  when  it  is  obvious  that  rest  will  not 
be  of  any  avail.  The  incisions  are  planned  to  expose  the 
cavity  of  the  joint  to  its  fullest  extent,  yet  to  avoid  its 
main  ligaments  and  tendons  as  far  as  possible.  The  knee- 
joint  may  be  opened  either  by  an  incision  across  the  patella, 
or  by  division  of  the  ligamentum  patellae,  the  knee-cap 
being  turned  upwards.  If  any  fistulous  tracts  exist,  the 
incision  may  be  carried  through  them.  The  synovial  mem- 
brane and  peri-articular  tissues  are  first  examined,  all  the 
pulpy  granulation  tissue  is  carefully  removed  from  before 
backwards  with  a  pair  of  forceps  and  scissors,  particular 
care  being  taken  to  clear  out  all  the  pockets,  and  to  follow 
the  diseased  tissue  where  it  has  insinuated  itself  between 
the  ligaments  and  tendons.  The  semilunar  cartilages  and 
the  crucial  ligaments  are  next  picked  clean,  or  even  re- 
moved entirely  if  they  are  greatly  diseased ;  otherwise, 
they  should  be  left,  though  the  synovial  prolongations 
in  their  neighbourhood  are  carefully  severed  with  blunt- 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E   I  3  I 

pointed  scissors.  The  condyles  of  the  femur  are  made  to  pro- 
ject, and  the  posterior  part  of  the  capsule  is  explored  and 
cleaned  as  thoroughly  as  possible,  a  1  in  10  solution  of  zinc 
chloride  being  applied  to  those  parts  which  cannot  other- 
wise be  reached.  The  condition  of  the  bones  and  articular 
cartilages  next  engages  the  attention  of  the  operator. 
They  are  scraped  and  gouged  until  all  ulcerated  patches 
have  been  removed,  and  for  this  purpose  a  variety  of 
gouges  curved  in  different  ways  will  be  required.  The 
articular  surface  of  the  patella  is  not  to  be  overlooked. 
The  bleeding  points  having  been  dealt  with  as  they  occur — 
since  the  bloodless  method  is  not  adopted  in  this  operation 
— the  whole  of  the  joint  cavity  is  again  swabbed  out  with 
the  solution  of  zinc  chloride.  It  is  afterwards  well  flushed 
with  sterilised  water ;  for  if  the  caustic  be  not  thoroughly 
washed  away,  the  after-pain  will  be  greatly  exaggerated. 
Provision  is  made  for  the  most  efficient  drainage,  if  it  is 
considered  necessary ;  though  here,  as  in  other  cases,  it  is 
better  to  avoid  the  use  of  a  drainage-tube  if  it  be  possible. 
The  patella  or  the  ligamentum  patella?.,  and  the  lateral 
ligaments,  if  they  have  been  divided,  are  carefully  sutured 
with  horsehair,  and  the  wound  is  closed.  An  antiseptic 
gauze  dressing,  with  plenty  of  absorbent  wool  over  it,  is 
applied  to  the  knee.  The  limb  is  bandaged  from  the  feet 
upwards,  and  is  then  fixed  upon  a  straight  back  splint. 
The  drainage-tube  is  removed  as  soon  as  practicable.  In 
many  instances  the  suppuration  is  very  prolonged,  in  others 
granulations  sprout,  cloacae  are  formed,  and  a  succession 
of  secondary  operations  have  to  be  done ;  but  in  some  of 
the  cases  I  have  seen,  the  patient  has  ultimately  had  per- 
fect use  in  the  limb.  All  our  efforts  to  prevent  the  spread 
of  the  disease  sometimes  prove  futile,  and  excision,  or  even 
amputation,  has  to  be  performed  in  order  to  save  the  life  of 
the  patient. 


I32      THE    SURGICAL    DISEASES    OF    CHILDREN 

Excision  of  a  joint  consists  in  removing  the  whole  of 
the  articular  surfaces  for  injury  or  disease,  and  allowing 
either  bony  or  fibrous  anchylosis  to  take  place  between 
the  ends  of  the  bones.  In  children's  practice,  excision  is 
only  done  for  tuberculous  disease.  The  operation  is  per- 
formed by  most  surgeons  at  a  later  period  in  the  disease 
than  ar three tomy,  but  by  its  most  thoroughgoing  advo- 
cates it  is  carried  out  at  a  comparatively  early  period. 
Mr.  Howse,7  for  instance,  says  that  when  a  well-marked 
case  of  pulpy  disease  has  lasted  over  six  months,  it  is  not 
worth  while,  in  the  interests  of  the  patient,  to  attempt  the 
conservation  of  the  joint  for  a  longer  period  ;  but  in  saying 
this,  he  does  not  wish  it  to  be  understood  that  he  would 
advise  the  excision  of  every  joint  which  has  been  affected 
with  tuberculous  disease  for  six  months.  The  advantages 
claimed  for  the  operation  are,  that  it  affords  a  speedy  and 
permanent  cure  of  the  disease,  that  a  thoroughly  service- 
able limb  is  left,  and  that  the  risk  of  tuberculous  infection 
is  proportionately  lessened. 

Indications  for  Excision  of  the  Knee.— Mr.  Howse 
sums  up  the  cases  in  which  excision  of  the  knee  should  be 
performed,  under  the  following  heads  : — 

1.  In  all  cases  in  which  the  disease  has  advanced  so  far 
as  to  cause  flaking  of  the  articular  cartilage,  and  grating 
in  the  movement  of  the  joint,  whether  suppuration  be 
evidently  present  or  not. 

2.  Cases  in  which  softening  of  the  ligaments  has  ex- 
tended so  far  as  to  give  rise  to  backward  displacement  of 
the  tibia. 

3.  All  cases  of  over  six  months'  duration,  in  which  there 
is  reason  to  believe  that  the  disease  has  started  in  an 
epiphyseal  osteitis,  which  has  given  rise  secondarily  to 
changes  in  the  cartilage. 

4.  Cases   of    extensive   suppuration   in   the   knee-joint. 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E  [33 

All  cases  of  this  description  which  have  started  from  pulpy 
mischief  should  be  excised.  In  suppuration  which  is 
pygemic  in  its  origin,  incision  should  be  first  practised,  and 
excision,  only  after  evidence  has  been  obtained  of  damage 
to  the  cartilages,  or  of  such  damage  to  the  ligaments  as  to 
have  caused  displacement. 

5.  Cases  in  which  the  pulpy  infiltration  of  the  synovial 
membrane  has  advanced  to  any  considerable  degree  over 
the  articular  cartilage. 

6.  Cases  in  which  pulpy  infiltration  has  extended  be- 
yond the  capsular  ligament  to  the  crucial  ligaments  and 
semilunar  cartilages. 

Mr.  Howse  probably  has  had  a  larger  experience  in 
excision  of  the  knee  than  any  surgeon  living,  so  that 
we  may  assume  that  these  indications  are  the  correct 
ones  for  excision  of  this  joint.  Amputation,  on  the 
other  hand,  must  be  performed  in  cases  of  joint  mischief 
where  there  is  lardaceous  disease,  where  the  lungs  or 
viscera  are  affected,  where  the  emaciation  is  very  great, 
and  where  several  joints  are  affected.  Excision  is  not  a 
very  suitable  operation  when  the  joint  disease  is  accom- 
panied by  extensive  osteitis  or  periostitis,  or  where  the 
tuberculous  deposits  are  chiefly  peri-articular. 

The  knee  should  be  straightened  as  far  as  possible  before 
the  operation,  by  the  judicious  application  of  an  extension 
apparatus  and  a  moderate  weight  (fig.  15)  for  a  week  or 
ten  days.  The  extension  process  is  sometimes  assisted  by 
wrapping  the  whole  limb  in  a  mackintosh  and  then  passing 
steam  under  it  from  a  bronchitis  kettle,  so  that  the  joint 
is  put  into  an  extemporised  vapour  bath.  Chloroform  must 
be  given,  and  the  adhesions  must  be  gently  broken  down 
in  all  cases  where  an  extension  cannot  be  completed  by  the 
or  Unary  methods. 

There   are   many  methods   of   excising   the   knee-joint. 


134      THE    SURGICAL    DISEASES    OF    CHILDREN 

The  one  I  generally  use  consists  in  making  a  semilunar 
skin-flap  upwards,  by  cutting  across  the  flexed  joint  from 
the  back  of  one  condyle  to  the  back  of  the  other,  the 
knife  being  carried  over  the  front  of  the  leg,  just  above  the 
tubercle  of  the  tibia.  The  skin-flap  is  carried  upwards 
until  the  quadriceps  tendon  is  exposed.  This  is  divided, 
and  the  patella  is  turned  downwards.  The  joint  is  then 
laid  open  by  dividing  the  extrinsic  and,  if  necessary,  the 
intrinsic  ligaments  ;  a  very  sparing  use  of  the  knife  is 
sufficient,  as  the  diseased  tissues  are  very  soft. 

The  saw  is  then  applied  to  the  femur,  and  the  bone  is 
divided  transversely,  so  as  to  remove  the  condyles  to  the 
bottom  of  the  intercondyloid  notch,  care  being  taken  not 
to  encroach  upon  the  epiphysis.  The  bone  is  sawn  from 
before  backwards,  and  it  is  very  important  that  it  should  be 
cut  exactly  at  right  angles  to  the  long  axis  of  the  femur. 
This  can  be  ensured  in  two  ways  :  one  by  holding  the  bone 
over  the  end  of  the  operating  table  and  sawing  vertically 
towards  the  floor,  the  other  by  laying  it  at  full  length  upon 
the  table  and  sawing  until  a  good  groove  is  formed  in  the 
bone,  and  in  the  proper  direction,  when  the  knee  is  flexed 
and  the  sawing  is  completed.  The  head  of  the  tibia  is  then 
freed  by  carrying  a  knife  round  it  immediately  below  its 
articular  surface,  and  in  such  a  manner  as  to  divide  all  the 
soft  structures.  The  saw  is  applied  to  the  head  of  the 
tibia,  and  as  little  of  the  bone  is  removed  from  before  back- 
wards as  possible.  The  patella  is  removed  with  this  slice, 
for  the  ligamentum  patellae  was  divided  by  the  circular  in- 
cision. The  tibial  epiphysis  must  not  be  removed  ;  but  if 
the  bone  is  found  to  be  diseased  beyond  the  point  where  it 
is  sawn,  it  is  often  necessary  to  scoop  away  the  cancellous 
tissue  beyond  the  epiphyseal  line.  This  may  be  done 
safely  ;  for  so  long  as  the  circumference  of  the  bone  is  not 
trenched  upon,  no  harm  results. 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E  I  35 

The  operator  next  examines  the  soft  parts,  treating  them 
exactly  in  the  same  manner  as  in  an  arthrectomy  (p.  130), 
and  it  is  attention  to  this  detail  which  has  restored  excision 
to  that  place  in  surgery  which  a  few  years  ago  it  seemed  in 
danger  of  losing.  The  more  the  caseating  material  and  the 
pulpy  synovial  membrane  is  removed,  the  greater  is  the 
likelihood  of  obtaining  a  firm  and  bony  anchylosis  without 
relapses,  and  a  subsequent  malposition  of  the  limb.  Yet, 
practically,  it  is  impossible  to  remove  every  fragment  of 
the  pulpy  synovial  membrane ;  but  this  does  not  interfere 
with  speedy  and  perfect  repair,  if  only  the  bulk  be  taken 
away,  for  as  I  have  already  pointed  out,  there  are  strong 
reasons  for  believing  that  the  normal  inflammatory  pro- 
cesses are  able  to  deal  effectively  with  small  portions  of 
tuberculous  tissue,  though  they  are  unable  to  destroy  it 
when  it  occurs  in  bulk.  The  diseased  tissue  is  removed 
with  dissecting  forceps  and  a  pair  of  blunt  scissors  curved 
upon  the  flat,  and  especial  attention  is  paid  to  the  various 
pockets  and  folds  made  by  the  synovial  membrane. 

The  whole  of  the  joint  is  then  swabbed  with  a  solution 
of  chloride  of  zinc  (40  grains  to  the  ounce),  and  is  flushed 
with  boiled  water  at  a  temperature  of  105°  F.  The 
bleeding  is  stopped  by  ligatures  and  firm  pressure.  The 
periosteum  is  then  divided  at  corresponding  points  on  the 
inner  and  outer  sides  of  the  femur  and  tibia,  and  a  drill 
is  passed  obliquely  through  the  bones.  Sutures  of  stout 
silver  wire  or  aseptic  silk  are  passed  through  the  holes. 
A  drainage-tube  is  then  laid  along  the  back  of  the  joint,  so 
that  it  projects  upon  either  side,  and  the  sutures  in  the 
bone  are  drawn  tight,  so  that  the  two  raw  surfaces  are 
kept  in  accurate  apposition.  The  skin  is  united  by  point 
sutures,  the  main  ones  of  silver  and  the  secondary  ones  of 
horsehair.  There  is  a  very  great  divergence  of  opinion  as 
to  the  utility  of  peeing  the  l>  mes  together  after  excision  of 


I36      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  knee  :  many  surgeons  still  considering  that  it  is  a  iiseful 
if  not  an  integral  part  of  the  operation,  whilst  many,  and 
perhaps  the  majority,  discard  pegs  altogether.  The  limb  is 
then  dressed  antiseptically  and  is  securely  fixed  in  an  ex- 
tended position,  either  in  a  plaster-of-Paris  splint,  which 
should  include  the  hip,  or  in  some  form  of  excision  splint. 

The  splint  employed  by  Mr.  Howse  (fig.  17)  consists  of 
two  shallow  troughs  of  sheet  iron,  tinned,  and  made  so  as 
to  fit  the  shape  of  the  leg  and  thigh.  The  foot-piece  works 
in  a  slot,  and  the  two  troughs  are  connected  at  the  back  by 


kneeG'  17-~Howse'8  8Plint"  with  a  8ning  cradle,  for  use  after  excision  of  the 

two  strong  bars  of  iron,  made  convex  transversely  so  as  to 
avoid  cutting  into  the  skin  of  the  popliteal  space.  The 
bars  are  so  arranged  that  the  interval  between  the  troughs, 
which  corresponds  to  the  excised  joint,  can  be  lengthened 
or  shortened  according  to  the  case  ;  and  this  interval,  even 
in  the  youngest  children,  should  never  be  less  than  four 
inches.  The  splint  also  has  a  small  pulley  at  the  bottom 
beyond  the  footpiece,  by  which  the  splint  is  slung  to  a 
cradle  as  soon  as  the  limb  is  secured.  Mr.  Howse  employs 
a  peculiar  system  of  fixation  which  he  considers  very 
effective.     It  will  be  found  to  be  described  in  detail  in  the 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E  I  37 

Gay's  Hospital  Reports,  vol.  xlix.,  1892.  The  first  dress- 
ing is  usually  required  at  the  end  of  forty-eight  hours, 
and  the  subsequent  ones  at  increasing  intervals. 

Abscesses  or  sinuses  which  are  formed  during  the 
healing  period  must  be  scraped  with  a  sharp  spoon,  and 
swabbed  out  with  a  solution  of  zinc  chloride  or  other 
caustic  in  the  ordinary  manner.  It  is  of  the  utmost 
importance  that  the  limb  should  be  maintained  absolutely 
immovable  for  at  least  three  months  after  the  operation ; 
and  throughout  this  time  the  greatest  care  must  be  taken 
to  maintain  the  leg  exactly  straight  with  the  thigh,  and  to 
overcome  the  tendency  which  the  thigh  evinces  to  become 
rotated  outwards,  whilst  the  leg  is  kept  by  the  splint  and 
bandages  in  its  normal  position. 

Bony  union  must  be  obtained,  or  the  operation  is  worse 
than  useless ;  and  when  the  splint  is  removed  and  the 
patient  is  allowed  to  get  about,  he  must  still  wear  a  leather 
splint  moulded  to  his  leg  and  thigh  for  a  prolonged  period, 
to  prevent  the  gradual  flexion  which  may  mar  the  best 
immediate  result. 

Ankle. 

Frequency  and  Pathology.  — Tuberculous  disease  of 
ankle  occurs  in  1575  per  cent,  of  cases,  so  that  it  is  less 
frequent  in  children  than  similar  affections  of  the  hip,  knee, 
and  elbow.  It  more  often  begins  in  the  bones  than  in  the 
synovial  membrane,  and  it  very  generally  commences  in 
the  cancellous  tissue  which  is  so  abundant  in  the  tarsal 
bones,  the  ankle  only  being  secondarily  affected.  The 
disease  is  always  progressive,  and  the  chronic  form  of 
hydrops  articuli,  which  is  common  in  adults,  is  practically 
unknown  in  children. 

Symptoms. — The  symptoms  are  those  which  are  com- 
mon to  tuberculous  disease  in  the  joints.    Swelling,  specially 


I38      THE    SURGICAL    DISEASES    OF    CHILDREN 

marked  upon  either  side  of  the  tendo  Achillis  ;  limping, 
although  the  child  can  still  walk  considerable  distances ; 
limited  joint  movement,  which  is  only  noticeable  at  first 
in  extreme  flexion  and  extreme  extension  ;  heat  over  the 
joint ;  pain  not  usually  well  marked,  and  wasting  of  the 

leg- 
Diagnosis. — A  diagnosis  has  to  be  made  as  to  whether 
the  disease  affects  the  ankle,  the  transverse  tarsal  joint,  or 
whether  it  is  confined  to  the  tendon  sheaths  outside  the 
joint ;  and  this  can  only  be  done  by  a  careful  examination 
under  chloroform. 

Course. — Suppuration,  with  the  formation  of  sinuses  and 
slow  ulceration  of  the  articular  cartilages,  frequently  takes 
place.  The  symptoms  are  so  ill-defined  that  the  parents 
often  do  not  understand  the  serious  nature  of  the  disease, 
and  the  child  is  therefore  not  brought  for  advice  until  the 
disease  has  made  very  serious  progress. 

Treatment.  (1)  Palliative. — Few  joint  diseases  yield 
more  readily  to  rest,  if  it  be  taken  in  time.  A  well- 
applied  plaster-of-Paris  case  for  the  ankle,  with  a  Thomas' 
knee-splint  (fig.  16)  to  keep  the  affected  foot  off  the 
ground,  will  cure  the  patient,  if  at  the  same  time  he  be  put 
under  good  hygienic  conditions.  In  some  cases  it  is  more 
advisable  to  apply  a  plaster  case  to  the  ankle,  and  to  make 
the  patient  use  a  knee-rest,  so  that  his  foot  does  not  come 
in  contact  with  the  ground. 

(2)  Operative  Treatment. — When  the  sinuses  have 
formed,  or  when  there  is  clear  evidence  that  the  tarsal 
bones  are  infiltrated  with  caseating  tubercle,  the  diseased 
spots  should  be  exposed,  scraped,  swabbed  with  zinc 
chloride,  flushed,  and  packed  with  camphorated  naphthol 
on  gauze. 

Arthrectomy  is  required  for  the  somewhat  rarer  cases 
in  which  the  disease  is  essentially  synovial  in  origin,  and 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS/E  I  39 

Mr.  Clutton  has  obtained  most  excellent  results  from  this 
method,  using  multiple  incisions  and  utilising  for  this 
purpose  the  sinuses. 

Amputation  is  required  in  a  few  rare  cases  where  the 
joint  is  disorganised,  when  there  are  extensive  sinuses, 
and  when  the  general  condition  of  the  child  forbids  the 
hope  of  recovery  from  any  less  severe  measure.  Syme's 
amputation  is  the  best  operation  to  perform,  even  if  the 
disease  involves  the  lower  end  of  the  tibia.  After  remov- 
ing the  foot  and  sawing  off  the  malleoli,  all  the  granula- 
tion tissue  should  be  scraped  away ;  the  diseased  centre 
of  the  tibia  should  also  be  removed,  taking  care  to  leave  a 
ring  of  bone  intact.  The  whole  of  the  inflamed  surfaces 
should  be  swabbed  with  a  1  in  15  solution  of  chloride  of 
zinc,  and  after  they  have  been  well  flushed,  the  flap  should 
be  attached  with  primary  point  sutures  of  silver  wire  and 
secondary  sutures  of  horsehair.  A  drainage-tube  may  be 
laid  in  the  posterior  part  of  the  wound,  but  it  should  be 
removed  on  the  second  or  third  day.  Union  by  the  first 
intention  usually  takes  place  even  in  the  worst  cases,  the 
sinuses  close  at  the  same  time,  and  only  rarely  present  any 
recurrence  of  tuberculous  disease. 

Tuberculous  Inflammation  of  Burs.e. 

The  large  bursse  in  the  neighbourhood  of  joints  in  chil- 
dren sometimes  become  affected  with  tuberculous  inflam- 
mation, leading  either  to  a  passive  serous  effusion  or  to 
suppuration.  There  is  no  doubt  as  to  the  tuberculous 
nature  of  the  lesion,  as  the  scar  left  after  laying  open  the 
bursa  sometimes  becomes  the  seat  of  a  tuberculous  inflam- 
mation which  may  render  its  removal  necessary. 

^Etiology. — The  exciting  cause  is  usually  a  slight  injury, 
and  I  have  more  often  seen  the  bursa  over  the  great  tro- 
chanter affected  than  that  in  other  parts,  no  doubt  because 


I4-0      THE    SURGICAL    DISEASES    OF    CHILDREN 

it  is  especially  liable  to  injury  in  children,  as  they  so  often 
fall.  There  is  every  proof  that  during  the  early  stages 
the  inflammation  is  strictly  limited  to  the  bursa.  The 
child  does  not  limp  or  complain  of  pain,  there  is  no  rise  of 
temperature,  no  muscular  fixation  of  the  neighbouring 
joint,  and  if  an  anaesthetic  be  given,  the  bone  moves  freely 
in  its  socket.  The  child's  attendant  usually  discovers  the 
swelling  accidentally,  and  comes  for  advice  about  it. 

Diagnosis. — These  passive  enlargements  of  bursa?  are 
often  of  very  serious  import,  and  are  of  great  diagnostic 
value,  for  they  are  frequently  the  first  indications  of  tuber- 
culous mischief  occurring  in  a  patient  who  otherwise 
appears  sound.  They  must  be  distinguished  from  simple 
abscesses  in  bursa?,  and  from  secondary  infection  of  the 
bursse  due  to  tuberculous  arthritis,  which  is  the  more 
frequent  cause  of  such  a  condition.  The  slighter  consti- 
tutional disturbance  will  distinguish  the  tuberculous 
from  the  traumatic  abscesses,  whilst  the  early  appearance 
of  the  swelling,  the  joint  being  still  healthy,  will  distin- 
guish the  primary  from  the  secondary  form  of  the  disease. 

Prognosis.  —  The  prognosis  must  be  guarded,  for 
tuberculous  trouble  thus  starting  in  a  bursa  will  spread 
rapidly  to  the  neighbouring  joint,  unless  care  be  taken  to 
prevent  it. 

Pathology.— The  joint  may  be  affected  by  extension 
along  the  lymphatics,  or  by  the  direct  spread  of  tuber- 
culous inflammation  from  the  bursa,  as  by  the  bursting 
of  the  abscess  into  its  cavity ;  but  this  does  not  happen 
if  ordinary  care  be  taken.  The  second  method  is  more 
insidious,  but  at  the  same  time  the  more  frequent.  The 
child  is  on  the  verge  of  tubercle,  for  the  bacilli  have  estab- 
lished themselves  in  a  single  bursa,  and  have  there  caused 
a  passive  effusion.  The  tubercle  bacilli  have  been  able  to 
effect  this  lodgment  owing  to  the  slight  injury  which  the 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.-E  I4I 

bursa  sustained,  for  this  led  to  a  diminished  resistance  on 
the  part  of  its  tissues.  The  congestion  produced  in  the 
neighbourhood  by  the  inflammation  of  the  bursa  is  suffi- 
cient to  enable  the  tubercle  bacilli  to  effect  a  further 
lodgment,  and  thus  an  arthritis  is  started.  The  followers 
of  Metchnikoff's  teaching  would  explain  the  sequence  of 
events  in  a  somewhat  different  manner.  Thus,  the  con- 
gestion leads  to  increased  multiplication  of  tubercle  bacilli. 
Increased  multiplication  of  bacilli  means  increased  invasion 
of  the  affected  tissues  by  the  various  forms  of  leucocytes 
attracted  in  virtue  of  their  chemotactic  properties.  The 
destruction  of  the  phagocytic  and  other  leucocytes  which 
then  takes  place  gives  rise  to  the  caseating  masses  known 
as  tubercle.  These  masses  are  destructive  to  the  functions 
of  the  joint  in  which  they  are  formed,  and  if  they  become 
septic,  are  even  inimical  to  life  itself.  The  following  cases 
illustrate  the  main  features  of  this  form  of  bursal  enlarge- 
ment : — 

Case  1. — A  delicate  and  very  intelligent  girl,  aged  8 
years,  was  brought  to  me  because  she  had  a  swelling  on 
the  outer  side  of  her  left  thigh.  She  appeared  to  be  quite 
healthy  in  every  other  respect,  and  she  had  been  running 
about  as  usual,  until  her  mother  accidentally  noticed 
the  swelling  about  a  week  previously.  There  was  an 
obscure  history  of  the  child  having  fallen  out  of  bed  six  or 
eight  weeks  before  the  appearance  of  the  swelling.  The 
Bwelling  was  in  the  situation  of  the  bursa  over  the  great 
trochanter  on  the  right  side ;  it  was  clearly  a  cold  abscess, 
and  the  skin  was  absolutely  healthy.  The  child  was  put  to 
bed,  her  thigh  was  rendered  aseptic,  and  the  abscess  was 
opened  on  the  day  after  I  first  saw  her.  There  was  no 
doubt,  when  she  had  been  anaesthetised,  that  her  hip-joint 
was  healthy.  Six  or  eight  ounces  of  pus  escaped,  and  a 
Inge  quantity  of  tuberculous  material  was  scraped  away 


142      THE    SURGICAL    DISEASES    OF    CHILDREN 

with  a  sharp  spoon.  I  introduced  my  finger  and  assured 
myself  that  the  abscess  was  confined  to  the  bursa,  and  that 
it  did  not  in  any  way  communicate  with  the  joint.  The 
cavity  was  then  thoroughly  flushed  with  a  warm  solution 
of  boric  acid,  was  closed  with  horsehair  sutures,  without  a 
drainage-tube,  and  was  dressed  with  antiseptic  gauze.  The 
dressings  were  left  untouched  for  a  week  ;  it  was  then 
found  that  the  wound  had  healed,  and  that  the  swelling 
had  disappeared,  but  that  there  was  a  little  fulness  beneath 
the  scar.  The  sutures  were  removed,  some  clear  serous 
fluid  escaped  through  one  of  the  suture  holes,  and  the 
wound  was  again  dressed  with  wet  gauze.  Three  days 
later  fluid  had  again  collected  beneath  the  line  of  incision 
to  such  an  extent  that  the  scar  became  stretched  ;  gentle 
pressure  opened  one  of  the  suture  holes  which  had  become 
closed  by  a  small  scab,  and  permitted  of  the  escape  of 
about  an  ounce  of  very  clear  and  yellow  serous  discharge. 
This  continued  to  drain  away  for  ten  days  and  gradually 
ceased.  Three  weeks  after  the  operation  the  child  was 
sent  home  cured. 

Case  2. — A  delicate  girl,  aged  4  years,  who  had  suf- 
fered from  superficial  keratitis,  was  admitted  under  my 
care  into  the  Victoria  Hospital  on  June  4th.  Her  left  but- 
tock was  noticed  to  be  swollen  eight  days  previously.  She 
walked  well,  but  could  not  sit  with  comfort.  It  was  found 
on  examination  that  the  left  buttock  distinctly  fluctuated, 
and  that  the  swelling  extended  from  the  crest  of  the  ilium 
to  three  or  four  inches  below  the  great  trochanter.  An 
incision  was  made  into  it,  and  eight  ounces  of  shreddy  pus 
were  let  out.  It  was  clear,  when  a  finger  was  put  into  the 
cavity,  that  the  abscess  had  been  formed  in  the  multilocular 
bursa  situated  between  the  glutseus  maximus  and  the  great 
trochanter.  The  abscess  wall  was  thoroughly  scraped 
away,  the  cavity  was  washed  out  with  boric  lotion,  and 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURSAL  I43 

the  wound  was  closed  with  horsehair  sutures.  It  healed 
by  first  intention,  the  child  went  home  cured,  and  she 
has  remained  well  ever  since. 

Case  3. — A  girl,  aged  6  years,  was  admitted  into  the 
Victoria  Hospital  under  the  care  of  Mr.  Pick.  She  began 
to  halt  on  the  left  leg  five  weeks  before  admission.  She 
had  a  large  fluid  swelling  behind  the  left  hip.  The  joint 
was  freely  movable,  and  did  not  appear  to  Mr.  Pick  to  be 
in  any  way  affected,  as  there  was  neither  shortening, 
flexion,  nor  abduction  of  the  limb.  An  incision  behind  the 
great  trochanter  allowed  of  the  removal  of  much  caseous 
material.  The  cavity  which  then  remained  extended  be- 
neath the  gluteus  maximus  as  far  as  the  finger  could  reach. 
It  had  no  connection  either  with  the  hip-joint  or  with  the 
bone.  The  wound  remained  open  for  some  time,  but  the 
child  was  kept  at  rest  and  with  an  extension  apparatus. 
She  was  discharged  six  weeks  later  in  a  plaster-of-Paris 
case,  and  with  a  patten  on  the  sound  foot. 

Case  4. — A  girl,  aged  1  year,  was  admitted  to  the 
hospital  under  my  care,  with  a  fluid  swelling  about  the 
size  of  a  hen's  egg  situated  over  the  great  trochanter.  The 
movements  of  the  hip  were  absolutely  unimpaired,  but  the 
child  was  ill  and  had  digestive  troubles.  An  incision  was 
made  into  the  swelling,  and  three  ounces  of  yellowish  red 
pus  were  let  out.  It  was  again  clear,  when  the  finger  was 
introduced  into  the  cavity,  that  the  abscess  had  been 
formed  in  the  bursa.  Three  weeks  later  the  wound  had 
almost  healed,  but  the  thigh  was  flexed  at  the  hip  and 
there  was  much  lordosis.  An  extending  weight  of  a  poiind 
was  attached  to  the  leg.  Three  days  later  the  child's 
general  and  local  condition  had  greatly  improved.  She 
had  regained  her  appetite,  the  leg  was  straight,  and  she 
had  no  lordosis.  Six  weeks  later  her  usual  posture  in 
bel  was  on  her  back  kicking  both  legs  freely  in  the  air. 


144      THE    SURGICAL    DISEASES    OF    CHILDREN 

She  was  therefore  sent  home  as  cured.     It  is  obvious  that 
this  child  just  escaped  an  attack  of  tubercular  arthritis. 

Case  5. — A  boy,  aged  4\-  years,  was  admitted  into  the 
hospital,  under  the  care  of  Mr.  Waterhouse,  on  account  of 
an  enlarged  patellar  bursa.  The  knee  appeared  to  be  un- 
affected. The  bursa  was  dissected  out,  and  was  found  to 
be  the  seat  of  tubercular  disease.  Primary  union  of  the 
wound  took  place  at  every  part  except  where  a  small 
drainage-tube  had  been  inserted,  and  there  a  sinus  formed. 
The  knee  became  affected  with  pulpy  degeneration,  and 
six  weeks  later  it  was  found  to  need  excision.  On  opening 
the  joint  for  this  purpose  the  synovial  membrane  was  seen 
to  be  invaded  everywhere  by  tubercular  granulation  tissue. 
There  was  no  disease  either  of  the  cartilages  or  of  the 
bones.  A  continuous  tract  of  tubercular  tissue,  however, 
could  be  traced  from  the  old  scar  at  the  side  of  the  pre- 
patellar bursa  to  a  spot  in  the  synovial  membrane  of  the 
knee,  just  above  the  patella,  where  the  tubercular  material 
had  iindergone  caseation.  This  case  differs,  therefore, 
from  the  preceding  ones  in  the  fact  that  the  joint  became 
affected  by  direct  extension  from  a  tubercular  focus. 

Case  6. — I  was  asked  to  see  a  boy  of  17,  employed  as  a 
gardener  in  a  small  village,  who  had  developed  a  painless 
fluid  swelling  in  the  situation  of  the  bursa  over  the  great 
trochanter.  He  evinced  an  unconquerable  aversion  to 
leaving  home,  or  to  any  form  of  treatment  by  rest.  He 
continued  his  occupation  from  the  time  I  saw  him  in  March 
until  the  end  of  July.  His  hip  then  became  affected  with 
acute  arthritis,  and  in  two  months  he  was  dead  of  general 
tuberculosis. 

It  is  evident  from  these  cases  that  passive  enlarge- 
ment of  the  bursse  in  children  is  of  considerable  importance 
both  in  diagnosis  and  in  prognosis  :  in  diagnosis,  because 
effective  treatment  should  be  adopted  at  once;  in  pro£ 


>g- 


TUBERCULOUS  DISEASES  OF  JOINTS  AND  BURS.E  1 45 

nosis,  because  it  is  clear  that  unless  great  care  be  taken 
the  worst  results  are  to  be  apprehended. 

Treatment. — The  treatment  to  be  adopted  is  that  given 
in  the  successful  cases,  and  it  follows  directly  from  the 
pathology.  If  the  passive  effusion  into  the  bursa  be  seen 
before  suppuration  has  occurred,  the  fluid  should  be  let  out 
by  means  of  an  incision  rather  than  by  aspiration.  Why, 
we  know  not,  but  we  do  know  that  in  such  passive  effusions 
due  to  tubercle,  and  notably  in  tubercular  peritonitis  with 
simple  effusion,  a  cure  more  often  follows  after  a  free 
incision  than  after  a  puncture,  even  though  the  wound 
heal  by  first  intention.  If  suppuration  has  occurred,  the 
abscess  must  be  opened,  scraped,  thoroughly  cleansed,  and 
every  effort  must  be  made  to  get  it  to  heal  at  once.  Union 
by  first  intention  is  of  vital  importance  in  these  cases,  for 
if  it  can  be  secured  the  patient  will  in  all  probability  escape 
further  trouble. 

Suitable  precautions  are  to  be  taken  at  the  same  time  to 
secure  physiological  rest  for  the  joint,  whilst  the  general 
hygiene  of  the  patient  must  be  improved ;  for  it  should 
never  be  forgotten  that  when  the  bursse  are  enlarged  in 
this  manner,  the  patient  has  already  passed  the  threshold 
of  tubercular  disease.  If  the  wound  fail  to  heal  by  first 
intention,  there  is  danger  lest  the  slight  increase  of  inflam- 
mation so  produced  may  hasten  the  tubercular  process,  and 
thus  the  operation  will  have  done  more  harm  than  good. 
It  is  perhaps  better  for  this  reason  not  to  insert  a  drain- 
age-tube, but  to  close  the  wound  in  its  whole  extent. 


CHAPTER  VII 

TUMOURS  AND  SYPHILITIC  DISEASE  OF 

BONE 

TUMOURS  OF  BONE. 

Innocent  tumours  of  bone  occur  more  frequently  in  children 
than  sarcomata.  They  are  chondromata,  exostoses,  and 
much  more  rarely  lipomata  and  cysts. 

Chondromata. 

Chondromata  spring  either  from  the  interior  of  short 
bones,  like  the  phalanges,  or  they  grow  subperiosteally  in 
the  neighbourhood  of  the  epiphyses  of  long  bones.  They 
may  also  grow  from  the  bones  of  the  skull ;  but  whatever 
may  be  their  origin,  they  are  innocent,  though  in  some 
cases  they  may  attain  so  large  a  size  as  to  render  the  limb 
useless  and  necessitate  amputation.  They  are  recognised 
by  their  hardness  and  by  their  immobility.  They  grow 
slowly  and  are  usually  painless. 

Treatment. — No  operation  is  needed  in  the  case  of 
enchondromata  of  the  fingers,  unless  they  are  unsightly, 
cumbersome,  or  rapidly  growing.  They  can  often  be 
extirpated,  but  occasionally  more  radical  measures  are 
necessary.  They  frequently  undergo  calcification,  and  they 
may  suffer  mucoid  and  fatty  degeneration ;  in  some  cases 
cysts  are  formed  in  them. 

146 


TUMOURS    AND    SYPHILITIC    DISEASE    OF    BONE     1 47 

Exostoses. 

Exostoses  originate  either  from  chondromata  which 
have  become  ossified,  or  they  are  formed  directly  by  the 
periosteum ;  the  latter  are  the  rarer.  They  are  usually 
situated  near  that  epiphysis  which  grows  most  quickly. 
They  may  be  single,  or  they  may  occur  in  very  large 
numbers  in  different  parts  of  the  skeleton.  The  single 
exostoses  growing  near  an  epiphysis  either  originate  outside 
the  joint  from  the  epiphyseal  line,  or  much  more  rarely 
from  just  within  its  capsule,  in  which  case  they  are  en- 
closed in  the  synovial  membrane,  when  they  appear  to 
originate  from  the  articular  cartilage  itself.  It  is  of  great 
importance  to  remember  the  latter  variety,  as  any  attempt 
to  remove  such  a  tumour  will  involve  opening  the  joint. 
There  is  usually  no  difficulty  in  recognising  exostoses,  al- 
though their  typical  appearance  is  sometimes  masked  by  an 
adventitious  bursa  which  is  occasionally  formed  over  them, 
and  by  the  fact  that  in  some  cases  they  consist  of  two 
parts,  one  superimposed  upon  the  other,  and  separated  by 
a  kind  of  false  joint.  Ivory  exostoses  are  less  frequently 
seen  in  children  than  in  adults,  but  when  they  are  met 
with  they  occur  in  similar  situations. 

Exostoses  are  usually  painless,  even  in  parts  subject  to 
constant  irritation,  for  they  are  protected  by  a  cap  of 
cartilage. 

Treatment. — Palliative  means  are  generally  sufficient 
for  their  treatment,  though  it  may  occasionally  be  neces- 
sary to  remove  them,  as  when  they  spring  from  the 
terminal  phalanx  of  a  toe.  When  they  spring  from  the 
epiphyseal  line,  they  may  become  attached  to  the  diaphysis 
instead  of  to  the  epiphysis,  and  so  may  be  carried  upwards 
until  they  are  found  at  some  distance  from  the  extremity. 
They  are  then  likely  to  be  mistaken  for  sarcomata. 


I48      THE    SURGICAL    DISEASES    OF    CHILDREN 

Parosteal  Lipomata. 

Parosteal  lipomata  sometimes  grow  from  or  are  inti- 
mately connected  with  the  periosteum  of  long  bones,  to 
which  they  are  attached  by  a  very  broad  base.  I  showed 
an  instance  of  such  a  growth  at  the  Pathological  Society  of 
London,  in  1888.  It  was  taken  from  a  boy,  aged  9  years, 
who  was  admitted  into  St.  Bartholomew's  Hospital,  under 
the  care  of  Mr.  Smith.  He  had  a  soft,  painless,  and  elastic 
swelling  extending  over  the  upper  third  of  the  left  thigh, 
and  along  its  outer  aspect.  The  skin  was  normal  and  freely 
movable  over  the  tumour,  but  the  superficial  veins  were 
slightly  distended.  The  tumour  weighed  15  ozs.  after 
removal,  and  was  divided  into  several  lobes.  In  spite  of 
this  case  being  well  impressed  on  my  mind,  I  mistook  the 
last  example  that  I  saw  for  a  chronic  abscess  of  the  thigh. 
These  tumours  are  always  congenital,  and  may  be  mistaken 
for  an  abscess  or  for  a  sarcoma,  the  only  certain  means 
of  diagnosis  being  an  exploratory  puncture  with  an  aseptic 
grooved  needle.  They  had  better  be  removed  when  their 
size  hampers  the  movement  of  the  limb. 

Fibrous  Epulis. 

Fibrous  epulis  is  a  hard  and  dense  tumour,  covered  with 
healthy,  congested,  or  ulcerated  mucous  membrane.  It 
usually  springs  from  the  gums  between  two  teeth  or  from 
the  periodontal  membrane,  and  it  projects  more  upon  the 
lingual  than  upon  the  buccal  side  of  the  alveolus.  The 
tumour  grows  slowly,  and  I  have  only  seen  it  in  connection 
with  the  permanent  dentition. 

The  Treatment  consists  in  extracting  a  tooth,  and  it 
sometimes  happens  that  the  epulis  comes  away  with  it ;  if 
it  does  not,  it  must  be  removed,  and  if  necessary,  a  part  of 
the  jaw  must  be  taken  away  as  well.  The  growths  do  not 
recur. 


TUMOURS    AND    SYPHILITIC    DISEASE    OF    BONE    1 49 

Cystic  Tumours  of  Bone. 

Cystic  tumours  of  bone  are  either  simple,  parasitic, 
or  malignant  (p.  150). 

Dentigerous  Cysts  occur  either  in  the  upper  or  lower 
jaw,  and  usually  in  connection  with  the  permanent  denti- 
tion. They  form  single  tumours,  which  expand  the  bone  as 
they  grow,  and  are  filled  with  a  clear  serous  fluid.  They 
may  be  due  to  errors  of  development  in  the  tooth  sac, 
to  faulty  position  of  the  teeth,  to  normal  persistence  of 
a  deciduous  tooth  which  should  be  shed  to  make  room  for 
its  successor,  or  to  the  presence  in  the  jaw  of  super- 
numerary teeth. 

Treatment. — The  cyst  should  be  laid  open  without 
making  any  skin  incision,  as  soon  as  its  nature  is  recog- 
nised, and  the  tooth  removed.  The  bones  soon  recover 
their  natural  shape  and  size. 

Parasitic  Cysts  are  due  either  to  hydatids  or  to  actino- 
mycosis, but  both  are  so  rare  in  England  that  they  do  not 
require  more  than  to  be  mentioned  here. 

SARCOMATA. 

The  malignant  tumours  of  bone  are  either  endosteal, 
of  which  the  myeloid  form  is  limited  to  children  and  to 
young  adults,  or  it  is  periosteal,  taking  the  form  of  round 
or  spindle-celled  growths,  of  which  the  ossifying  sarcoma 
presents  somewhat  peculiar  features.  The  jaws  and  the 
long  bones  are  particularly  obnoxious  to  the  growth  of 
sarcomata,  but  an  infiltrating  form  of  sarcoma  is  not  very 
uncommon  in  the  bones  forming  the  vault  of  the  skull. 
Some  of  these  cases  run  an  acute  course,  and  become  very 
widely  disseminated.  Nothing  can  be  done  for  them,  and 
they  fortunately  soon  involve  the  brain,  leading  to  uncon- 


I50      THE    SURGICAL    DISEASES    OF    CHILDREN 

sciousness.     The  sarcomatous  growth,  in  one  case  which  I 
saw,  was  of  a  sage-green  colour  (p.  446). 

Myeloid  Sarcomata. 

Myeloid  sarcomata  are  nearly  always  central  in  origin. 
They  spring  from  the  long  bones  near  their  articular 
ends,  and  they  occur  more  often  in  young  adults  than  in 
children.  They  grow  slowly,  and  cause  such  expansion 
of  the  bone  that  it  may  become  a  mere  shell,  which  eventu- 
ally gives  way  and  allows  the  growth  to  infiltrate  the 
surrounding  tissues  and  to  spread  and  disseminate  like  a 
periosteal  sarcoma.  Such  endosteal  sarcomata  are  usually 
cystic  ;  they  may  pulsate,  they  rarely  affect  the  articular 
cartilages,  and  they  lead,  in  some  cases,  to  spontaneous 
fracture.  The  tumours  they  produce  are  usually  of  an 
ovoid  or  spheroidal  shape,  except  when  they  grow  sub- 
periosteally,  and  they  are  then  irregular  and  lobed. 

Prognosis. — The  prognosis  is  not  so  bad  as  for  other 
sarcomata  in  children,  recurrence  is  somewhat  less  likely 
to  occur,  and  when  it  does  occur  the  secondary  growths 
are  not  necessarily  of  the  myeloid  type,  for  they  may  con- 
sist of  any  other  form  of  sarcomatous  tissue.  The  lymphatic 
glands  are  more  often  implicated  in  children  than  in 
adults. 

Treatment. — The  treatment  consists  in  excising  the 
affected  portion  of  the  bone,  or  in  the  enucleation  of  the 
growth  when  it  is  limited  and  the  case  has  been  seen 
early.  Amputation,  however,  should  be  performed  if  there 
is  any  reason  to  suppose  that  the  surrounding  parts  are 
affected ;  for  when  this  has  been  done,  there  is  the  least 
likelihood  of  a  recurrence. 

Blood  Tumours.— Mr.  Roughton  has  recently  dealt 
with  the  blood  tumours  of  bone.  They  are  of  great  rarity, 
and  he  considers  that  they  are  sometimes  angeiomata  and 


TUMOURS    AND    SYPHILITIC    DISEASE    OF    BONE    I  5  1 

sometimes  angeio-sarcomata.  He  quotes  a  case  in  which 
such  a  tumour  was  clinically  innocent,  though  microscopic 
examination  showed  that  it  contained  myeloid  cells.  The 
case  was  that  of  a  girl,  aged  4  years,  who  hurt  her  leg  by 
a  fall  ten  months  before  she  came  under  Mr.  Roughton's 
care.  A  tumour  slowly  developed  in  the  interior  of  the 
tibia,  and  gradually  expanded  the  bone  until  eggshell 
crackling  could  easily  be  detected.  There  was  neither 
pain,  tenderness,  redness,  nor  oedema  ;  the  knee-joint  was 
natural,  and  there  was  no  enlargement  of  the  lymphatic 
glands  either  generally  or  locally.  The  thigh  was  slightly 
wasted,  probably  from  disuse.  The  contents  of  the 
tumour  proved  to  be  a  dark  red  fluid,  looking  like  altered 
blood  and  serum.  The  cavity  was  stuffed  with  lint,  and 
eventually  healed  well. 

Malignant  Epulis. 

The  sarcomatous  epulis  grows  from  the  periosteum  of  the 
alveolar  border  of  the  jaw — the  upper  more  often  than  the 
lower — and  from  the  first  is  of  a  much  more  livid  colour 
than  the  fibrous  epulis.  The  lividity  is  partly  due  to  pig- 
ment granules,  which  are  present  both  in  the  cells  and 
in  the  stroma  of  its  tissue.  A  malignant  epulis  usually 
contains  numerous  giant  cells.  It  does  not,  however,  run 
a  very  malignant  course,  and  there  is  no  recurrence  if  it 
is  removed  by  resecting  a  piece  of  the  jaw.  Neither  form 
of  epulis  should  be  mistaken  for  the  mass  of  "proud  flesh," 
which  is  sometimes  seen  in  children's  gums  as  a  result  of 
carious  teeth,  or  after  extraction ;  for  these  growths  are 
much  softer,  bleed  more  freely,  and  are  clearly  not  covered 
with  mucous  membrane. 

Periosteal  Sarcomata. 
The  periosteal  sarcomata  spring  from  the  deeper  layers  of 


152      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  periosteum  of  any  of  the  long  bones.     They  are  either 
round  or  spindle-celled,  mixed  or  fibrous. 

^Etiology. — They  may  occur  at  any  time  in  childhood, 
and  are  seen  even  in  infants.  They  can  be  traced  a  little 
more  frequently  to  direct  injuries  in  children  than  in 
adults ;  otherwise,  they  run  a  similar  course  and  must  be 
treated  upon  the  same  lines.  The  tumours  grow  more 
rapidly  and  disseminate  more  freely  than  in  older  persons. 
Ossifying  Sarcoma. — Sarcoma  affects  the  long  bones 
and  the  cranial  bones  in  children. 

Diagnosis. — It  is  very  likely  to  be  mistaken  for  a 
tuberculous  arthritis  of  the  knee  when  it  grows  from  the 
lower  end  of  the  femur ;  or  it  may  be  looked  upon  as  an 
osteitis,  a  chronic  abscess  of  bone,  or  as  a  mass  of  peri- 
articular gummata.  It  may  be  distinguished,  however, 
from  all  these  conditions  by  its  steady  increase  in  size, 
and  by  the  early  enlargement  of  the  lymphatic  glands 
when  the  cylindrical  bones  are  affected. 

Symptoms. — The  tumour  grows  rapidly,  so  that  the 
disease  runs  an  acute  course.  The  annexed  case,  which 
I  narrated  some  years  ago  at  the  Pathological  Society, 
illustrates  the  ordinary  course  of  the  affection. 

A  girl,  aged  13,  noticed  a  slight  pain  and  stiffness  in 
her  left  knee  immediately  after  a  long  country  walk. 
The  stiffness  continued,  in  spite  of  treatment  for  three 
months ;  but  it  was  not  severe,  and  the  patient  was  able 
to  do  her  ordinary  school  work.  Her  knee  was  observed 
to  be  swollen  three  months  after  the  stiffness  was  first 
complained  of,  and  it  was  treated  for  ttiberculous  syno- 
vitis. The  swelling  increased  rapidly,  and  an  enlarged 
and  densely  hard  gland  appeared  in  the  groin.  Her  thigh 
was  amputated  in  the  middle  third,  and  a  month  later  the 
enlarged  gland  was  removed  from  the  groin.  It  was  then 
found  to  be  so  firmly  attached  posteriorly  to  the  sheath  of 


TUMOURS    AND    SYPHILITIC    DISEASE    OF    BONE    1 53 

the  femoral  vessels  that  an  inch  of  the  femoral  vein  had 
to  be  removed  with  it.  A  mass  of  new  growth  was 
detected  in  the  pelvis,  shortly  after  the  removal  of  the 
gland,  and  a  month  before  the  death  of  the  patient  there 
were  symptoms  of  a  secondary  deposit  in  the  lungs. 

Treatment. — This  case  and  others  like  it  show  that  the 
only  effective  treatment  is  amputation  of  the  limb  as  soon 
as  the  diagnosis  is  established,  and,  if  possible,  before  the 
glands  are  affected  and  before  dissemination  has  taken 
place. 

SYPHILITIC  DISEASE  OF  BONE. 
Syphilis  attacks  the  bones  of  children  in  several  ways. 

Long  Boxes. 

(1)  Osteomyelitis  is  one  of  the  very  earliest  symptoms 
of  inherited  syphilis.  The  long  bones  of  children  under 
a  week  old  are  sometimes  found  to  be  affected  with  a 
plastic  osteomyelitis,  chiefly  affecting  the  periosteum,  pro- 
ducing bony  deposits,  and  leading  to  thickening  of  the 
epiphyseal  lines.  The  epiphyseal  lines  themselves  are 
affected  primarily  in  children  under  three  months  old. 

Symptoms. — The  symptoms  are  ill-defined,  for  the  child 
does  not  appear  to  be  in  pain  until  his  limbs  are  handled, 
he  is  lethargic,  and  he  does  not  move  about  like  a  healthy 
baby.  Examination  of  his  limbs  shows  that  there  is  a 
marked  thickening  at  the  line  of  the  epiphysis  in  several 
of  the  long  bones,  and  a  diagnosis  of  rickets  is  therefore 
often  made.  In  course  of  time,  if  he  be  left  untreated,  the 
enlargement  increases,  and  one  or  more  of  the  epiphyses 
separate,  so  that  the  limbs  become  quite  helpless.  Sup- 
puration occasionally  takes  place,  the  abscess  usually 
bursting  externally,  though  the  joint  is  sometimes  involved. 
If   the  child   dies   before   suppuration   has   occurred,  the 


154      THE    SURGICAL    DISEASES    OF    CHILDREN 

thickening  of  the  epiphyseal  lines  is  found  to  be  due  to 
the  formation  of  a  semi-transparent  gelatinous  material, 
containing  small  yellow  nodules  of  gummatous  substance, 
and  it  has  a  great  tendency  to  suppurate  or  to  caseate. 
The  degeneration  is  sometimes  red  instead  of  yellow. 
This  condition  has  been  carefully  studied  by  Parrot,  who 
has  given  it  the  name  of  chondro-osteitis. 

Diagnosis.— It  has  to  be  distinguished  from  rickets, 
scurvy,  chronic  septic  osteomyelitis,  and  osteosarcoma,  as 
well  as  from  the  earlier  stages  of  tuberculous  disease  of 
the  epiphyses. 

Prognosis. — Its  prognosis,  even  in  the  worst  cases,  is 
most  satisfactory.  I  have  seen  one  or  two  cases,  how- 
ever, in  which  such  inflammation  of  the  epiphysis  led  to 
permanent  shortening  of  the  bone. 

Osteomyelitis  also  occurs  in  older  children.  The  radius 
and  ulna  and  the  tibia  are  most  often  affected,  but  the 
vertebrae  and  the  phalanges  do  not  always  escape.  This 
form  of  syphilitic  spine  and  syphilitic  dactylitis  is  likely 
to  be  mistaken  for  its  more  common  tuberculous  congener. 
Syphilis,  however,  affects  the  periosteum  more  than 
tubercle,  and  in  the  spine  the  syphilitic  deposit  takes 
place  at  more  than  one  spot,  with  intervening  healthy 
tissue,  whilst  in  tubercle  the  lesion  is  rarely  multiple. 

(2)  Osteitis. — A  chronic  sclerosing  osteitis  sometimes 
affects  the  long  bones,  and  leads  to  their  thickening  and 
bending.  Necrosis  takes  place  in  other  cases,  associated 
with  great  rarefaction  of  the  surrounding  bones.  Lastly, 
there  is  a  true  gummatous  ulceration  of  the  long  bones, ' 
associated  with  a  similar  condition  of  the  joints.  This 
occurs  in  young  adults,  and  is  more  fully  described  at 
page  231. 

(3)  Decalcification. — A  remarkable  decalcification  of  the 
bones  sometimes  takes  place  in  syphilitic  children  between 


TUMOURS    AND    SYPHILITIC    DISEASE    OF    BONE    I  55 

the  ages  of  five  and  six  months.  The  decalcification  is 
occasionally  general,  and  it  is  then  likely  to  be  mistaken 
for  rickets,  and  to  be  treated  ineffectually.  It  may  be 
confined  to  one  or  two  bones,  and  it  then  seems  to  be  the 
result  of  a  local  gummatous  deposit,  which  may  lead  to 
that  variety  of  spontaneous  fracture  which  is  occasionally 
seen  in  the  ribs. 

Skull. 

The  bones  of  the  skull  are  affected  by  syphilis  in 
a  manner  similar  to  the  long  bones,  though  less  fre- 
quently. Hutchinson  and  Parrot  first  drew  attention  to 
the  fact  that,  at  variable  periods  within  the  first  two 
j-ears  of  life,  osteophytic  growths  appear  on  the  outer 
surface  of  the  cranial  bones,  and  in  definite  positions,  viz. 
on  the  frontals  and  parietals,  at  the  boundaries  of  the 
anterior  fontanelles,  extending  backwards  parallel  with  the 
sagittal  suture.  These  elevations  are  lens-shaped,  and  of 
a  violet  or  red  colour,  porous  in  character,  and  grooved  by 
vascular  channels.  They  extend  gradually,  and  bridging 
over  the  sutures  may  lead  to  synostosis  of  the  skull,  and 
so  to  a  condition  of  microcephalus.  Similar  conditions  are 
also  met  with  in  rickets,  so  that  in  difficult  cases  too 
much  stress  must  not  be  laid  upon  Parrot's  modes  in 
making  a  diagnosis  of  syphilis. 

Doughy  swellings,  which  may  ulcerate  or  suppurate, 
sometimes  appear  on  the  heads  of  syphilitic  children. 
They  present  the  ordinary  characters  of  soft  nodes,  and 
may  do  serious  injury  to  the  bones,  for  they  may  cause 
craniotabes,  or  that  condition  of  the  skull  in  which  the 
bones  yield  and  feel  like  parchment  when  pressure  is  made 
upon  them.  The  process  of  ulceration  commences  on  the 
outer  side  of  the  bone,  is  well  defined,  and  of  limited 
extent.     It  may  be  distinguished  from  the  craniotabes  of 


156      THE    SURGICAL    DISEASES    OF    CHILDREN 

marasmus  and  rickets  by  the  fact  that  it  is  not  limited  to 
the  part  of  the  skull  which  is  most  liable  to  pressure,  for 
it  may  involve  the  parietals  and  the  anterior  part  of  the 
occipital  bones. 

M.  Parrot  also  describes  an  atrophic  lesion  of  the  skull, 
due  to  a  gelatiniform  transformation  of  the  bony  material, 
similar  to  that  seen  in  the  epiphyseal  lines. 

A  sclerosing  process  is  sometimes  seen  in  the  skulls  of 
young  adults  who  have  been  the  subjects  of  inherited 
syphilis,  for  the  calvaria  is  very  thick  and  dense,  and  the 
sutures  are  wholly  absent.  The  syphilitic  disease  of  the 
skeleton  is  characterised  by  its  slow  course  and  by  its 
painlessness. 

Diagnosis. — It  has  to  be  distinguished  from  acute 
osteomyelitis,  from  tuberculous  disease,  and  from  sarcoma. 
The  disease  is  sudden  in  onset  in  osteomyelitis ;  it  is 
attended  with  more  fever,  and  the  swellings  suppurate 
more  readily.  It  is  often  difficult  to  distinguish  the  bony 
lesions  of  syphilis  from  those  produced  by  tubercle.  The 
condition  of  the  child,  its  snuffles,  its  muddy  complexion, 
the  rash  about  its  anus,  the  peeling  of  the  palms  of  its 
hands  and  the  soles  of  its  feet,  and  the  mucous  patches 
about  its  mouth  and  anus,  will  serve  to  complete  the 
differential  diagnosis  in  young  children ;  whilst  in  older 
ones  the  stunted  growth,  the  peg-topped  and  crescentically 
notched  permanent  incisors,  the  deafness,  and  the  intersti- 
tial keratitis  will  serve  the  same  purpose.  Sarcoma  is 
only  likely  to  be  mistaken  for  syphilitic  disease  of  bone  in 
its  earliest  stages,  for  it  runs  a  rapid  course  in  children, 
and  very  soon  involves  the  soft  parts. 

Prognosis. — The  prognosis  of  syphilitic  disease  in  chil- 
dren is  most  satisfactory,  even  in  the  worst  cases. 

Treatment. — One-grain  doses  of  grey  powder  three  times 
a  day  for   a   child   of   six  or  eight  weeks  old,  with  the 


TUMOURS    AND    SYPHILITIC    DISEASE    OF    BONE   1 57 

inunction  of  a  5  per  cent,  solution  of  oleate  of  mercury,  or 
of  blue  ointment,  soon  work  a  marvellous  change.  The 
child  in  a  very  short  time  loses  its  marasmic  condition,  its 
pseudo-paralysis  disappears,  for  the  separated  epiphyses 
reunite,  sinuses  and  fistulse  close,  and  the  patient  is  rapidly 
restored  to  health. 


CHAPTER   VIII 

INJURIES   OF   BONES 

FRACTURES  AND   SEPARATED  EPIPHYSES. 

etiology. — Fractures  in  children  present  several  inter- 
esting deviations  from  similar  injuries  in  adults.  Apart 
from  those  produced  by  direct  or  indirect  violence,  there 
are  intra-uterine,  congenital,  ricketty,  and  spontaneous 
varieties.  The  ordinary  traumatic  fractures  are  most 
frequent  in  children  under  twelve,  in  the  radius,  humerus, 
clavicle,  femur,  and  leg.  The  jaws,  nose,  fingers,  and 
skull  are  less  often  broken,  whilst  the  sternum,  scapula, 
and  pelvis  are  only  damaged  after  the  most  extensive 
injuries.  In  addition  to  the  injuries  of  bones  usually 
met  with  in  adults,  children  present  two  special  forms — the 
"  greenstick  "  fracture,  and  separation  of  the  epiphyses. 

Symptoms. — The  symptoms  of  fracture  are  the  same  as 
in  adults,  but  are  not  usually  so  well  marked.  It  should 
be  remembered  in  making  a  diagnosis  that  the  pain  of  a 
fracture  in  a  child  is  often  inconsiderable,  whilst  the 
crepitus  may  be  much  less  distinct  than  it  is  in  an  older 
person,  partly  because  the  periosteum  remains  unruptured 
in  a  certain  proportion  of  cases,  and  partly  because  the 
separation  may  not  involve  ossified  tissues,  if  it  has  taken 
place  near  an  epiphysis.  The  deformity,  too,  is  often 
much  less,  because  the  fracture  is  not  so  oblique,  and 
the  muscles  are  weaker.  Inattention  to  these  points, 
and  the  difficulty  of  recognising  "  greenstick  "  fractures, 

158 


INJURIES    OF    BONES  I  59 

may  lead  inexperienced  surgeons  to  overlook  a  fracture 
which  is  only  too  obvious  as  soon  as  callus  has  been  pro- 
duced. Such  errors  in  diagnosis  react  in  two  ways — upon 
the  surgeon  by  lessening  the  parents'  confidence  in  him, 
and  upon  the  child  by  increasing  the  risk  of  an  ununited 
fracture  from  want  of  restraining  apparatus. 

Course. — Fractures  in  children  heal  with  great  rapidity, 
and,  as  a  rule,  with  great  certainty,  owing  to  the  activity 
of  the  formative  processes  which  take  place  in  their  bones, 
and  there  is  often  an  exuberant  formation  of  callus.  The 
subsequent  modelling  process  is  carried  out  so  perfectly, 
that  after  a  few  months  it  is  often  impossible  to  ascertain 
the  exact  seat  of  the  injury,  even  when  a  section  of  the 
bone  is  made. 

Sequelae. — The  sequelae  of  fractures  are  few.  I  have 
seen  non-union  in  various  bones,  the  persistence  of  de- 
formity and  shortening,  chiefly  after  injury  near  the 
epiphyses,  and  crossed  union  in  the  bones  of  the  forearm, 
owing  to  carelessness  in  the  application  of  splints.  Gan- 
grene may  be  produced  by  the  application  of  too  tight  a 
bandage,  but  it  is  fortunately  of  very  rare  occurrence. 

Treatment. — The  general  treatment  consists  in  imme- 
diate and  perfect  reduction,  and  this  is  especially  necessary 
in  separated  epiphyses,  so  that  an  anaesthetic  is  often 
required,  and  the  subsequent  application  of  appropriate 
restraining  apparatus.  Nothing  is  better  for  this  pur- 
pose than  a  well-fitting  plaster-of-Paris  splint  or  case. 
Non-union  I  believe  to  be  nearly  always  due  to  imperfect 
fixation  of  the  broken  ends  of  the  bone.  Its  prognosis 
is  very  unsatisfactory  in  children,  for  in  spite  of  wiring, 
grafting  pieces  of  bone  or  periosteum,  local  irritation,  and 
other  means,  a  useless  limb  too  often  results,  and  ampu- 
tation may  have  to  be  performed.  A  few  successful  cases 
of  wiring  are  on  record,  and  in  ununited  fracture  of  the 


l6o      THE    SURGICAL    DISEASES    OF    CHILDREN 

clavicle,  at  any  rate,  a  useful  arm  may  exist  in  spite  of 
non-union  of  the  fragments. 

Spontaneous  Fractures. 

"  Spontaneous  fractures  "  are  those  resulting  from  violence 
which  would  be  insufficient  to  break  a  long  bone  under 
ordinary  conditions.  They  are  secondary  to  other  diseases 
of  bones,  to  muscular  action,  or,  much  less  commonly,  to 
trophic  changes  connected  with  diseases  of  the  central 
nervous  system.  Sometimes,  as  in  scurvy,  they  are  due 
to  constitutional  causes,  and  some  children  and  families 
seem  to  have  peculiarly  brittle  bones  without  any  other 
evidence  of  ill-health  (see  p.  161).  It  is  also  associated 
with  phosphaturia,  and  it  is  met  with  in  diabetes ;  sarco- 
mata or  other  endosteal  tumours  lead  to  it.  Spontaneous 
fracture  of  the  tibia  is  sometimes  the  result  of  an  osteitis 
caused  by  injury. 

I  have  seen  a  spontaneous  fracture  of  the  tibia  in  a 
child  who  had  central  necrosis  of  the  femur,  in  which,  after 
amputation  of  the  thigh,  the  tibia  and  fibula,  though  physio- 
logically healthy,  were  reduced  to  a  mere  shell,  and  even 
the  compact  tissue  was  riddled  with  holes  until  it  looked 
like  lace-work,  the  changes  being  due  to  interference  with 
the  blood  supply,  resulting  from  the  chronic  inflammatory 
changes  in  the  thigh.  Spontaneous  fracture  is  said  to 
occur  in  some  cases  of  infantile  paralysis  of  long  stand- 
ing, as  a  result  of  advanced  degenerative  changes  taking 
place  in  the  bone,  and  it  is  even  less  frequently  met  with  in 
cases  of  hydrocephalus.  Such  cases  of  spontaneous  frac- 
ture must  not  be  confused  with  the  spontaneoiis  separation 
of  the  epiphyses  which  takes  place  shortly  after  birth,  as  a 
result  of  syphilis,  or  with  the  spontaneous  fractures  some- 
times connected  with  changes  in  the  bone  during  the  early 
stages  of  rickets.     In  syphilis  and  rickets  the  prognosis 


INJURIES    OF    BONES  l6l 

of  spontaneous  fracture  is  good,  for  under  the  influence  of 
appropriate  treatment  repair  takes  place,  whereas  in  the 
other  cases  it  is  bad,  and  amputation  will  be  required. 

Osteopsathyrosis. 

Spontaneous  fractures  occurring  in  scurvy  must  be  dis- 
tinguished from  spontaneous  multiple  fractures  occurring 
in  individuals  who  have  an  hereditary  tendency  to  frac- 
ture.12 

Etiology. — We  know  very  little  of  this  remarkable 
condition,  except  that  the  bones  repeatedly  become  broken 
as  the  result  of  very  slight  violence. 

Symptoms. — The  symptoms  are  those  of  an  ordinary 
fracture,  except  that  there  is  less  pain,  with  less  swelling 
and  bruising  of  the  soft  tissues. 

Diagnosis. — Osteopsathyrosis  or  fragilitas  ossium  must 
be  distinguished  from  the  other  causes  producing  spontan- 
eous fracture  which  have  been  enumerated  above. 

The  number  of  fractures,  the  good  health  of  the  child, 
and  the  history  of  heredity,  transmitted  solely  in  the  male 
or  in  the  female  line,  are  siimcient  to  make  certain  the 
diagnosis  of  true  osteopsathyrosis. 

Prognosis. — The  prognosis  is  good,  for  the  fractures 
repair  well  under  the  ordinary  methods  of  treatment.  In  a 
case  in  the  St.  Bartholomew's  Hospital  Museum,  however, 
which  was  under  the  care  of  Mr.  Langton,  who  has  kindly 
given  me  leave  to  publish  the  details,  the  patient  died 
with  sarcoma  at  the  age  of  thirty.  At  eleven  years  old 
he  fractured  the  upper  part  of  his  right  humerus  whilst 
he  was  throwing  a  cricket  ball ;  the  bone  united.  In  1874 
he  slipped  and  fell,  fracturing  his  left  humerus ;  the  bone 
united.  In  November,  1878,  he  fell  whilst  playing  foot- 
ball, and  again  fractured  his  right  humerus  just  above 
the  condyles ;  the  bone  united.     In  June,   1880,  he  broke 

M 


1 62      THE    SURGICAL    DISEASES    OF    CHILDREN 

his  right  femur  by  a  twist,  owing  to  his  left  leg  slipping 
under  him :  the  bone  broke  as  he  stood ;  it  united  partially, 
but  not  firmly,  and  there  was  much  eversion.  In  spite  of 
the  non-union,  and  although  there  were  three  inches  of 
shortening,  the  patient  said  that  he  could  walk  sixteen 
miles  in  a  day,  at  the  rate  of  three  and  a  half  miles  an 
hour.  His  right  heel  slipped  whilst  coming  downstairs  in 
February,  1884,  and  to  save  himself  from  falling  he  swung 
round,  grasping  the  banisters  with  both  hands  ;  the  left 
femur  broke  above  the  condyles  as  he  was  standing,  but 
he  did  not  fall.  The  union  was  satisfactory.  The  bone, 
however,  began  to  bend  at  the  seat  of  fracture  two  years 
later,  and  movement  began  three  and  a  half  years  after 
the  injury.  In  September,  1888,  he  noticed  movement  at 
the  seats  of  fracture  of  the  right  humerus,  owing,  as  he 
said,  to  excessive  use.  In  April,  1889,  a  sarcoma  formed 
in  the  right  arm,  which  grew  until  November,  1889,  when 
it  was  deemed  advisable  to  remove  the  arm  at  the  shoulder. 
Recurrence  took  place  in  the  scar  in  February,  1890,  and 
the  patient  died  in  June,  1890,  from  secondary  deposits  in 
the  internal  organs. 

Intra-uterine  Fractures. 

There  appears  to  be  no  doubt  that  injuries  to  the 
abdomen  of  a  pregnant  woman  may  cause  one  or  more 
fractures  in  the  foetus.  Fractures  so  caused  usually  unite, 
sometimes  in  good  position,  sometimes  with  a  greater  or 
less  amount  of  deformity ;  occasionally  they  remain  un- 
united. Such  intra-uterine  fractures  are  of  course  to  be 
distinguished  from  true  congenital  fractures  produced  at 
the  time  of  birth. 

Traumatic  Separation  of  the  Epiphyses. 
These  accidents 13  are  necessxrily  confined  to  young  per- 
sons, though  different  epiphyses  are  liable  to  separation  at 


INJURIES    OF    BONES  1 63 

different  times.  Some  epiphyses,  like  that  of  the  femur, 
are  more  often  separated  early  in  life ;  whilst  others,  like 
the  olecranon,  are  only  separated  comparatively  late.  The 
separation  may  be  accurately  through  the  epiphyseal  line, 
as  is  usual  in  infants,  or  it  may  involve  a  portion  of  the 
shaft  of  the  bone,  as  is  not  unusual  when  the  injury  occurs 
between  the  ages  of  twelve  and  sixteen. 

Separation  of  the  epiphyses  occurs  most  frequently  at  the 
lower  end  of  the  femur,  next  at  the  upper  and  lower  ends 
of  the  humerus,  at  the  lower  end  of  the  radius,  and  at  the 
lower  end  of  the  tibia.  The  particular  dangers  of  epiphy- 
seal separation  lie  in  the  fact  that  the  joint  either  is  or 
may  be  affected,  for  the  capsule  in  many  joints  includes 
the  epiphyses,  as  may  be  seen  by  referring  to  the  coloured 
plate  (p.  96).  Some  epiphyses  are  more  liable  to  become 
displaced  after  they  have  been  separated  than  others,  for 
some  are  pulled  aside  by  the  muscles  attached  to  them, 
whilst  others  have  no  such  muscular  attachments.  Per- 
manent deformity  or  serious  secondary  injuries  may  there- 
fore be  produced  by  such  injuries,  even  when  the  greatest 
pains  have  been  taken  during  the  process  of  repair.  The 
periosteum  is  often  torn  away  from  the  shaft  of  the  bone  for 
a  considerable  distance  by  the  separation  of  an  epiphysis,  so 
that  periostitis  in  its  various  forms  may  result.  Suppuration 
is  by  no  means  uncommon,  even  after  a  simple  separation 
of  an  epiphysis,  due,  no  doubt,  to  the  tendency  which 
septic  micro-organisms  show  to  settle  in  the  neighbourhood 
of  an  injured  epiphysis.  Necrosis  results  from  this  sup- 
puration. Finally,  if  all  goes  well  immediately  after  the 
accident,  and  the  epiphysis  unites  firmly  and  in  good  posi- 
tion, premature  ossification  may  take  place,  leaving  a 
stunted  and  often  atrophied  limb. 

The  diseases  and  injuries  to  which  epiphyses  are  liable 
have   been  most   exhaustively  studied   by  Mr.  Jonathan 


164      THE    SURGICAL    DISEASES    OF    CHILDREN 

Hutchinson,  jun.,  and  by  Mr.  Tubby,  whilst  Mr.  Sturrock 
has  collected  many  interesting  examples. 

Fractures  of  the  Skull. 

.etiology.— Cranial  fractures  in  young  children  are 
always  the  result  of  direct  violence,  and  they  present 
certain  remarkable  peculiarities  which  mark  them  off  very 
clearly  from  similar  injuries  in  adults.  In  the  first  place, 
fractures  of  the  skull  are  uncommon  in  children,  for  the 
bones  are  so  thin,  homogeneous,  and  elastic  that  they 
readily  yield  to  external  violence,  and  bend  rather  than 
break.  Extensive  fissured  fractures,  therefore,  do  not 
occur  with  anything  like  the  same  frequency  that  they  do 
in  adults,  and  depressed  fractures  with  splintering  of  the 
inner  table  are  practically  unknown,  though  Mr.  Staveley 
reminds  me  that  the  Museum  of  St.  Thomas'  Hospital 
contains  a  typical  example  produced  by  the  pecking  of  a 
hen.  Their  place  is  taken,  however,  by  those  cases  in 
which  a  depressed  piece  of  bone  is  driven  beneath  the 
neighbouring  intact  bony  vault.  Permanent  depressions 
of  large  tracts  of  the  parietal  or  frontal  bones  are  not  rare, 
and,  on  the  other  hand,  I  have  seen  a  variety  of  green- 
stick  fracture  in  the  parietal  bones  marked  by  a  convexity 
beneath  the  pericranium,  following  injuries  received  during 
birth. 

Secondly,  as  Mr.  Rickman  Godlee  has  shown,  the  bones 
are  united  by  soft  sutures,  and  as  the  fontanelles  are  not 
closed,  the  whole  force  of  the  injury  falls  upon  the  part 
struck.  The  dura  mater  is  very  firmly  attached  to  the  in- 
terior of  a  child's  skull.  It  follows,  therefore,  from  these 
two  conditions  that  a  fracture  of  the  vault  is  nearly  always 
attended  by  laceration  of  the  dura  mater,  whilst  severe 
injuries  to  the  brain  substance  are  much  more  frequent  after 
such  accidents  in  children  than  they  are  in  adults.     The 


INJURIES    OF    BONES  1 65 

brain  injuries  are  often  overlooked,  partly  because  they  give 
rise  to  few  and  uncertain  symptoms, — for  a  child's  brain 
shows  great  power  of  adapting  itself  to  altered  conditions, 
— partly  because  such  symptoms  as  do  occur  after  a  slight 
compound  and  fissured  fracture  do  not  manifest  themselves 
until  many  days  or  weeks  after  the  injury,  and  partly 
because  the  thinness  of  the  bone  and  the  yielding  nature 
of  the  skull  allow  of  extensive  damage  to  the  skull  without 
laceration  of  the  scalp.  Cases  of  simple  fissured  fracture 
in  children  sometimes  gape  widely,  perhaps  because  the 
freely  movable  bones  allow  of  a  considerable  displacement 
of  the  fractured  parts.  Marchant  has  shown  that  in  frac- 
tures of  the  skiill  occurring  in  children  under  ten  years  of 
age,  rupture  of  the  middle  meningeal  artery  much  more 
frequently  gives  rise  to  external  haemorrhage  than  to  the 
ordinary  intracranial  haemorrhage. 

Hernia  cerebri  sometimes  results  from  a  compound  frac- 
ture of  the  skull.  It  is  a  dangerous  condition,  as  death 
often  results  from  meningitis,  or  from  inflammation  of  the 
cerebral  substance.  The  tendency  to  it  may  be  lessened 
by  keeping  the  wound  aseptic  ;  but  if,  unfortunately,  a 
hernia  should  occur,  the  granulation  tissue  must  be 
scraped  away,  the  soft  parts  may  then  be  refreshed, 
loosened,  and  brought  together  over  the  wound.  The 
pericranium  may  be  slightly  detached,  and  shavings  of 
fresh  bone,  obtained  from  some  other  part  of  the  body, 
may  be  introduced  into  the  aperture  in  the  skull  before 
the  wound  is  closed. 

Traumatic  Cephalhydrocele  or  Meningocele. 

A  remarkable  form  of  injury  occurs  in  very  young  chil- 
dren, to  which  Dr.  Conner  has  applied  the  name  traumatic 
cephalhydrocele,  though  it  is  better  known  as  traumatic 
meningocele.11 


1 66      THE    SURGICAL    DISEASES    OF    CHILDREN 

Symptoms. — The  condition  is  characterised  by  a  fluid 
swelling  developing  slowly  at  the  seat  of  injury  some  weeks 
after  a  fall  upon  the  head,  usually  in  children  under  three 
years  of  age.  The  swelling  in  some  cases  pulsates,  and  it 
may  have  a  respiratory  rhythm.  It  is  always  in  direct 
communication  with  the  subarachnoid  space,  for  if  it  is 
punctured  cerebro-spinal  fluid  escapes,  and  probably  in 
every  case  the  opening  in  the  skull  is  also  connected  with 
the  ventricles  of  the  brain. 

Pathology. — The  exact  pathology  of  these  swellings  is 
still  a  matter  of  doubt.  They  undoubtedly  start  from  a 
simple  fracture  of  the  skull,  associated  with  rupture  of  the 
dura  mater.  Mr.  Clement  Lucas  believes  that  there  has 
also  been  laceration  of  the  brain  substance,  reaching  to 
the  cavity  of  the  lateral  ventricles.  The  substance  of  the 
brain  softens,  and  there  is  an  increased  secretion  of  cerebro- 
spinal fluid  owing  to  the  irritation  thus  set  up.  The  pres- 
sure from  within  and  the  yielding  of  the  brain  together 
contribute  to"  the  escape  of  the  fluid  from  the  ventricles. 
A  hernia  of  the  cerebral  meninges  takes  place,  and  this,  by 
the  constant  pressure  which  it  exercises,  leads  to  absorp- 
tion of  bone ;  and  as  the  tumour  lies  outside  the  skull,  the 
absorption  of  the  bone  takes  place  from  without  inwards. 

Diagnosis. — The  diagnosis  is  easily  made  if  the  history 
can  be  obtained  correctly,  or  when  clear  cerebro-spinal 
fluid  is  drawn  off  through  an  aseptic  puncture.  The 
swelling  may  be  mistaken  for  a  hsematoma,  but  it  may 
be  distinguished  by  its  tendency  to  remain  stationary,  or 
to  increase  in  size,  whilst  a  hsematoma  diminishes.  The 
prognosis  is  grave. 

Treatment. — The  treatment  varies  in  individual  cases. 
Puncture  may  cure  the  tumour  when  the  opening  in  the 
skull  is  small ;  but  when  there  is  a  free  communication 
between  the  two  sides  of  the  cranial  bone,  it  is  unlikely 


INJURIES    OF    BONES  1 67 

that  much  good  will  follow  such  an  operation.  It  is  note- 
worthy that  most  of  the  reported  cures  have  taken  place 
where  no  operative  treatment  has  been  adopted,  whilst  in 
many  cases  death  from  meningitis  has  followed  tapping. 
The  surgeon  must  therefore  be  absolutely  sure  of  his 
asepsis  before  he  punctures  such  a  swelling. 

The  tumours  in  many  cases  are  stationary,  and  palliative 
treatment  by  the  use  of  a  gutta-percha  shield  is  perhaps 
best,  for  in  a  certain  proportion  of  cases  the  tumour  has 
disappeared  spontaneously. 

Fractures  of  the  Skull  in  Young  Adults. 

Fractures  of  the  skull  in  older  children  whose  skull  has 
consolidated  present  no  peculiarities.  They  follow  the 
same  course,  and  must  be  treated  upon  the  same  principles 
as  those  which  govern  similar  injuries  in  adults. 

Nasal  Bones. 

iEtiology. — I  have  seen  several  cases  of  broken  nose  in 
children  resulting  from  falls  upon  the  face,  or  in  older 
boys  from  diving  into  shallow  water  in  swimming  baths, 
as  well  as  from  other  forms  of  direct  violence. 

The  nature  of  the  injury  is  often  masked  by  the  effusion 
of  blood.  It  is  of  extreme  importance,  however,  to  recog- 
nise the  fracture  at  once,  for  repair  takes  place  by  first  in- 
tention, often  leaving  a  marked  deformity.  A  very  careful 
examination  under  chloroform  should  therefore  be  made 
in  all  cases  of  suspected  fracture,  that  is  to  say,  when  after 
an  injury  there  is  flattening  and  lateral  deviation  of  the 
nose.  Attention  must  be  paid  at  the  same  time  to  the 
condition  of  the  nasal  cartilages  and  the  septum  nasi,  as 
they  are  often  displaced,  either  wholly  or  in  part. 

Treatment. — There  is  usually  but  little  tendency  to 
displacement,  so  that  it  is  sufficient  to  replace  the  frag- 


1 68      THE    SURGICAL    DISEASES    OF    CHILDREN 

ments  in  the  proper  position.  If  it  is  difficult  to  maintain 
their  position,  however,  or  if  the  deformity  recurs,  Mason's 
treatment  must  be  adopted.  The  fragments  are  elevated 
and  replaced  by  means  of  a  pair  of  dressing  forceps,  and 
a  hare-lip  pin  is  passed  through  them  as  far  back  as 
possible.  Its  ends  are  cut  off  so  that  they  project  for  a 
short  distance  upon  either  side,  and  a  piece  of  adhesive 
strapping  or  an  india-rubber  band  is  passed  from  one 
end  to  the  other.  The  fragments  are  thus  supported 
posteriorly  as  well  as  laterally.  The  needle  should  be 
withdrawn  at  the  end  of  a  week. 

Lower  Jaw. 

Fractures  of  the  lower  jaw  are  very  rare  in  children  ; 
but  Hamilton  records  instances  and  gives  details  of  cases, 
as  well  as  of  one  which  would  have  been  called  a  green- 
stick  fracture  if  it  had  occurred  in  a  long  bone. 

Treatment. — A  gutta-percha  splint  should  be  made  for 
the  chin,  and  it  should  be  kept  in  place  by  a  four-tailed 
bandage  until  the  swelling  has  subsided.  A  mould  of  the 
alveolar  border  of  the  lower  jaw  should  then  be  taken  in 
wax.  A  Hammond's  splint  is  then  made  by  accurately 
adapting  a  piece  of  stout  silver  or  platinum  wire  round 
the  bases  of  the  teeth  in  a  cast  made  from  the  mould.  The 
ends  of  the  wire  being  soldered,  the  splint  is  transferred 
to  the  patient's  mouth,  and  is  kept  in  place  by  a  thin  silver 
wire  run  in  and  out  between  the  teeth. 

Clavicle. 
A  broken  collar-bone  is  one  of  the  commonest  accidents 
which  a  surgeon  is  called  upon  to  treat  in  infants  and 
young  adults,  and  it  is  the  one  most  frequently  over- 
looked. There  is  no  danger  of  mistaking  it  when  it  is 
complete,  and  there  is  a  clear  history  of  an  accident ;  but 
when  it  is  of  the  greenstick  variety,  when  the  periosteum 


INJURIES    OF    BONES  169 

is  intact,  and  when  a  careless  nurse  who  has  dropped  her 
baby  gives  a  purposely  misleading  history,  the  diagnosis 
is  often  most  difficult.  The  pain  is  then  often  attributed 
to  teething  or  other  trivial  causes,  and  close  and  prolonged 
observation  will  alone  show  that  the  injured  arm  is  not 
used  as  readily  as  the  opposite  one. 

Treatment. — The  treatment  for  an  infant  in  arms  con- 
sists in  binding  the  arm  to  the  side  with  a  roller  bandage, 
and  dressing  the  child  so  that  the  injured  arm  is  kept 
inside  its  clothes  for  a  fortnight ;  for  an  older  child  this 
is  supplemented  by  keeping  its  arm  in  a  sling  for  another 
week.  This  method  should  be  adopted  in  every  case  in 
which  a  fracture  is  suspected,  and  in  very  young  children 
it  is  a  safe  precaution  to  adopt  whenever  there  has  been 
an  injury  to  the  shoulder.  The  arm  should  be  kept  at 
rest  for  ten  days  in  doubtful  cases,  as  by  that  time  the 
formation  of  callus  will  establish  the  diagnosis,  whilst  if 
there  has  only  been  a  bruise  the  surgeon  will  have  erred 
upon  the  right  side.  The  only  cases  of  ununited  fracture 
of  the  clavicle  I  have  seen  were  those  in  which  the  injury 
had  been  overlooked  and  the  children  had  been  allowed  to 
go  about  without  any  restraining  apparatus. 

Sayre's  method  of  applying  two  pieces  of  stout  strap- 
ping is  as  effectual  for  young  adults  as  any  other.  One 
piece  of  strapping  three  inches  wide  is  stitched  loosely 
round  the  injured  arm  opposite  the  insertion  of  the  del- 
toid. An  assistant  is  directed  to  draw  the  arm  down- 
wards and  backwards  to  stretch  the  clavicular  fibres  of 
the  pectoralis  major,  and  whilst  this  is  being  done  the 
surgeon  carries  the  strip  backwards  round  the  body  so 
that  the  sticky  side  adheres  to  the  skin.  He  then 
stitches  the  end  to  the  encircling  band  in  the  middle  of 
the  back.  The  assistant  is  next  told  to  bring  the  elbow 
forwards  and  inwards  so  that  the  hand  lies  flat  upon  the 


I70      THE    SURGICAL    DISEASES    OF    CHILDREN 

opposite  shoulder.  The  humerus  is  thus  supposed  to  act 
as  a  lever,  throwing  the  shoulder  outwards  and  prevent- 
ing the  two  fragments  of  the  clavicle  overlapping  ;  but  I 
greatly  doubt  whether  its  action  is  more  than  temporary. 
A  second  piece  of  strapping  is  carried  obliquely  across  the 
sound  shoulder,  in  such  a  way  that  the  point  of  the  elbow 
on  the  injured  side  is  received  into  a  slit  made  in  the 
strapping,  whilst  the  hand  and  forearm  are  also  covered. 
A  flannelette  bandage  may  be  applied  over  the  whole  to 
keep  everything  in  place.  The  apparatus  is  left  on  until 
firm  union  has  taken  place,  which  is  usually  at  the  end  of 
a  fortnight  or  three  weeks. 

The  Epiphysis  of  the  Clavicle. 

The  sternal  extremity  is  sometimes  torn  off  in  young 
persons. 

The  Symptoms  are  undue  prominence  of  the  inner  end 
of  the  bone,  and  the  presence  of  a  sharp  bony  extremity 
beneath  the  skin.  Mr.  Christopher  Heath  says  that  in  a 
case  which  came  under  his  notice  in  a  boy,  aged  14,  the 
supra-sternal  notch  was  quite  distinct  and  equally  defined 
on  both  sides  ;  the  presence  of  a  thin  lamella  of  bone  on 
the  injured  side  could  be  clearly  detected  as  it  lay  between 
the  notch  and  the  gap  formed  by  the  forward  projection 
of  the  shaft  of  the  clavicle. 

Diagnosis. — Separation  of  the  epiphysis  has  to  be  dis- 
tinguished from  fracture  on  the  inner  side  of  the  rhomboid 
ligament,  but  the  fracture  is  farther  away  from  the  joint. 

The  Treatment  consists  in  keeping  the  patient  flat  upon 
his  back  in  bed  for  fourteen  days. 

Humerus. 

Every  variety  of  fracture  occurs  in  the  humerus  in 
children  ;  but  separation  of  the  epiphyses  and  injuries  to 
its  lower  extremity  are  of  more  especial  interest. 


INJURIES    OF    BONES  IJl 

Separation  of  the  Upper  Epiphyses. 

Separation  of  the  epiphyses  in  the  upper  end  of  the 
humerus  either  includes  the  head  of  the  bone,  or  it  chiefly 
involves  the  greater  tuberosity. 

Separation  of  the  whole  of  the  upper  epiphysis  takes 
place  after  the  sixth  year,  for  it  is  only  then  that  the 
nuclei  for  the  head  unite  with  that  of  the  greater  tuber- 
osity to  form  a  single  mass.  It  is  generally  met  with  about 
puberty,  and  the  separation  results  from  direct  violence 
to  the  shoulder.  It  is  likely  to  be  mistaken  for  a  sub- 
coracoid  or  sub-clavicular  dislocation.  Careful  examination 
will  show  that  the  head  of  the  humerus  lies  in  the  glenoid 
cavity,  whilst  in  some  cases  the  upper  end  of  the  lower 
fragment  can  be  felt  beneath  the  skin ;  in  this  case  the 
projecting  mass  of  bone  may  readily  be  mistaken  for  the 
head  of  the  humerus. 

Symptoms. — The  arm  is  helpless,  and  the  upper  end  of 
the  shaft  projects  abruptly  beneath  the  coracoid  process, 
so  that  the  axis  of  the  arm  is  altered  and  the  elbow 
is  directed  a  little  outwards  and  backwards.  There  is 
abnormal  mobility  just  below  the  shoulder- joint, — which  is 
best  demonstrated  by  abducting  the  humerus, — with  rapid 
swelling  about  the  shoulder  and  some  shortening  if  the 
diaphysis  is  wholly  displaced.  There  is  muffled  crepitus 
when  the  diaphysis  is  brought  into  contact  with  the 
separated  epiphysis.  The  deformity  can  be  reduced  by 
extension  and  counter-extension,  but  it  is  immediately 
reproduced  when  the  arm  is  left  to  itself. 

Prognosis. — The  prognosis  is  not  very  good,  for- as  Mr. 
Hutchinson,  jun.,  points  out  in  his  excellent  essay  on  the 
diseases  and  injuries  of  the  epiphyses,13  there  is  sometimes 
great  difficulty  in  maintaining  the  fragments  in  good 
position  when   the  upper  epiphysis  of   the  humerus   has 


172      THE    SURGICAL    DISEASES    OF    CHILDREN 

been  separated.  This  difficulty  he  attributes  to  the  fact 
that  there  may  be  a  longitudinal  rent  in  the  periosteum 
through  which  the  upper  end  of  the  shaft  projects,  and 
this  rent  may  have  to  be  enlarged  before  the  shaft  can  be 
replaced.  Good  union  does  not  take  place  readily  ;  but  in 
spite  of  this  a  useful  arm  results,  though  there  may  be 
some  shortening  from  interference  with  the  growth  of 
the  bone. 

Treatment. — Steady  traction  should  be  made  upon  the 
arm,  and  slight  abduction,  aided  by  a  rotatory  movement ; 
and  if  the  reduction  is  once  fairly  effected,  the  epiphyseal 
line  is  so  sinuous  that  the  parts  remain  in  fairly  good 
apposition.  Splints  should  be  applied,  and  the  shoulder 
treated  as  if  for  a  fracture,  by  flexing  the  forearm,  and 
bringing  it  forwards  so  that  the  fingers  lie  upon  the 
opposite  shoulder;  this  carries  the  elbow  well  across  the 
chest,  and  the  injured  arm  is  then  fixed  securely  with 
a  broad  flannel  bandage.  Some  means  of  extension  may 
be  employed  advantageously  in  older  children. 

Separation  of  the  Greater  Tuberosity. 

The  great  tuberosity  is  usually  torn  off  by  direct 
violence,  but  sometimes  it  has  been  separated  by  muscular 
effort.  The  tubercle  is  drawn  upwards  and  backwards 
towards  the  back  of  the  acromion  process,  whilst  the  shaft 
of  the  bone  is  drawn  upwards  and  inwards  by  the  sub- 
scapularis,  pectorales,  latissimus  dorsi,  and  anterior  fibres 
of  the  deltoid. 

Symptoms. — These  changes  in  position  lead  to  a  great 
widening  of  the  shoulder  and  a  marked  prominence  of  the 
coracoid  process  on  the  injured  side.  The  separated 
epiphysis  can  often  be  taken  between  the  finger  and 
thumb,  and  can  be  moved  into  its  natural  position ;  and 


INJURIES    OF    BONES  173 

if  the  arm  be  extended  at  the  same  time,  the  deformity 
can  be  temporarily  overcome. 

Treatment. — The  best  results  are  obtained  by  putting 
the  patient  to  bed,  raising  the  arm  above  the  head,  and 
securing  it  in  such  a  position  that  the  greater  tuberosity 
lies  over  its  point  of  separation.  The  surgeon  must  in 
many  cases  content  himself  with  applying  a  gutta-percha 
or  leather  cap  moulded  to  the  shoulder,  and  fitted  with  a 
pad  on  its  inner  surface,  with  the  object  of  retaining  the 
great  tuberosity  in  position,  when  from  any  reason  the 
child  cannot  be  kept  in  bed. 

Shaft. 

Fractures  of  the  .shaft  of  the  humerus  do  not  differ 
materially  in  their  causes,  symptoms,  or  treatment,  from 
similar  injuries  in  adults.  There  is  not  so  great  a  risk 
of  non-union  since  there  is  less  displacement  of  the 
fragments,  as  the  periosteum  is  often  less  torn  than  in 
adults.  Good  repair  usually  takes  place  in  a  fortnight 
under  any  method  of  fixation,  but  the  injured  arm  should 
not  be  used  for  a  month.  An  internal  angular  splint  with 
an  external  straight  splint  or  a  piece  of  a  "  kettle-holder  " 
(Gooch's)  with  a  sling  usually  affords  sufficient  fixation, 
and  I  prefer  it  to  a  plaster-of-Paris  splint,  at  any  rate  for 
the  first  fortnight. 

Elbow. 

Fractures  in  the  region  of  the  elbow  u  are  very  numerous 
and  very  complicated  in  children.  They  are  usually  the 
result  of  falls  in  young  children,  and  of  direct  violence  in 
older  ones. 

Treatment.  —Anchylosis  is  so  common  after  these  frac- 
tures in  the  immediate  neighbourhood  of  the  elbow  that 
there  is  the  greatest  diversity  of   opinion  in  respect  to 


174      THE    SURGICAL    DISEASES    OF    CHILDREN 

their  treatment.  One  school  of  surgeons  advocates  the 
arm  being  maintained  in  a  state  of  flexion,  whilst  another 
holds  with  equal  tenacity  that  extension  yields  the  better 
results.  I  prefer  the  flexed  position  myself,  and  I  always 
employ  it  in  these  cases.  The  method  adopted  by  Prof. 
Busch,  of  Bonn,  is  a  serviceable  one.  It  consists  in  main- 
taining the  limb  at  an  angle  of  about  120°  until  the 
swelling  has  subsided  ;  the  elbow  is  then  bent  to  an  acute 
angle  for  a  week  or  ten  days.  It  is  carefully  straightened 
under  an  anaesthetic  upon  the  twentieth  day  until  it  has 
been  extended  to  an  angle  of  180°,  and  the  splint  is  again 
applied  until  the  twenty-eighth  day,  when  it  is  per- 
manently laid  aside. 

A  formal  operation  may  have  to  be  performed  when 
anchylosis  has  taken  place,  if  the  adhesions  cannot  be 
broken  down.  The  joint  is  exposed  by  an  incision  carried 
along  its  outer  side,  the  callus  is  removed  or  the  articular 
ends  are  divided  with  a  chisel  until  the  fragments  can  be 
replaced  in  their  proper  relationship  to  each  other.  The 
arm  must  then  be  fixed  upon  a  rectangular  splint,  and  the 
case  treated  as  if  an  excision  had  been  performed. 

Separation  of  the  Lower  Epiphysis  of  the  Humerus. 

The  lower  epiphysis  may  be  separated  at  any  time  up 
to  the  13th  or  14th  year,  though  the  separation  is  somewhat 
more  frecpaent  in  children  under  four  years  of  age.  It 
ossifies  from  four  nuclei ;  that  for  the  internal  condyle 
forming  a  separate  epiphysis  from  that  of  the  articular 
surface  and  external  condyle,  and  uniting  with  the  shaft 
later. 

etiology. — The  lower  epiphysis  may  be  torn  off  by 
forcible  adduction  or  abduction,  and  it  sometimes  follows 
a  fall  upon  the  hand  with  the  elbow  bent. 


INJURIES    OF    BONES  I  75 

Mr.  Jonathan  Hutchinson,  jun.,  says  that  in  these  cases 
there  is  more  or  less  complete  backward  displacement  of 
the  epiphysis,  with  an  abnormal  projection  backwards  of 
the  olecranon,  more  marked  when  the  arm  is  extended  than 
when  it  is  bent.  There  is  therefore  an  increase  in  the 
antero-posterior  diameter  of  the  affected  elbow,  rendered 
more  marked  by  the  rapid  swelling  within  the  joint,  which 
is  a  usual  concomitant  of  the  injury.  Voluntary  movement 
is  limited,  but  there  is  abnormal  mobility  just  above  the 
elbow,  corresponding  to  a  line  drawn  transversely  at  or 
just  below  the  epicondyles. 

Diagnosis. — Separation  of  the  lower  epiphysis  must  not 
be  mistaken  for  a  backward  dislocation  of  the  radius  and 
ulna,  though  it  bears  a  superficial  resemblance  to  it,  as 
the  lower  fragment  is  tilted  backwards  beneath  the  triceps, 
whilst  the  upper  fragment  projects  forwards.  When  the 
radius  and  ulna  have  been  dislocated  backwards,  the  lower 
end  of  the  humerus  can  be  felt  to  bear  its  articular  sur- 
faces ;  whilst  after  separation  of  the  epiphysis  the  articular 
surfaces  are  carried  backwards  with  the  forearm,  and  only 
the  naked  end  of  the  shaft  of  the  humerus  projects  in  front. 
This  lower  end  sometimes  presses  upon  the  brachial  artery, 
until  it  has  caused  gangrene,  or  there  may  be  injury  to  the 
nerves. 

Treatment.— The  patient  should  be  put  to  bed,  and  his 
arm  laid  upon  a  Stromeyer's  cushion  with  the  elbow 
flexed.  An  evaporating  lotion,  consisting  of  equal  parts 
of  methylated  spirit  and  lotio  plumbi,  should  be  applied 
until  the  swelling  begins  to  subside.  A  plaster-of-Paris 
case  may  then  be  moulded  to  the  arm,  and  it  should  be 
kept  in  position  by  means  of  a  bandage  and  a  sling  for 
three  weeks.  The  child  may  leave  his  bed  after  the 
tenth  day. 


I76      THE    SURGICAL    DISEASES    OF    CHILDREN 

Supracondylar  Fractures  of  the  Humerus. 

iEtiology. — These  injuries  are  rare  in  children,  but 
when  they  occur  they  are  produced  by  a  fall  from  a  height 
or  by  a  blow  or  kick.    They  are  often  compound. 

Symptoms. — The  line  of  fracture  is  nearly  always 
oblique,  so  that  the  lower  fragment  projects  backwards 
beneath  the  triceps,  as  in  separation  of  the  lower  epiphysis. 
Gentle  extension  applied  to  the  forearm  reduces  the  de- 
formity, but  it  is  reproduced  as  soon  as  the  arm  is  left  to 
itself.  There  is  so  much  swelling  attending  both  these 
injuries,  and  they  are  often  so  obscure,  that  no  certain 
diagnosis  can  be  made  until  the  child  is  anaesthetised. 

Treatment. — Supracondylar  fractures  should  be  treated 
like  a  separation  of  the  epiphysis,  by  placing  the  arm 
midway  between  pronation  and  supination,  so  that  the 
thumb  is  uppermost.  The  elbow  is  bent  and  the  arm  is 
secured  to  a  well-padded  rectangular  plaster-of-Paris  splint 
applied  along  its  inner  side.  Passive  movement  should 
be  commenced  upon  the  twentieth  day,  and  the  muscles 
of  the  arm  should  then  be  shampooed  daily. 

T-Fracture. 

etiology. — The  supracondylar  fracture  in  children  is 
sometimes  complicated  by  a  vertical  fracture  extending 
downwards  through  the  lower  fragment  into  the  joint, 
thus  forming  the  well-known  T-fracture. 

Symptoms. — There  is  usually  no  difficulty  in  recog- 
nising this  form  of  fracture.  The  elbow  is  swollen  and 
shapeless,  the  joint  is  full  of  blood ;  and  if  the  child  be 
anaesthetised,  the  fragments  of  bone  can  readily  be  moved 
upon  each  other. 

Prognosis. — The  prognosis  in  these  cases  is  of  necessity 
grave,  for  the  joint  is  seriously  implicated  ;  but  the  repara- 


INJURIES    OF    BONES  1  77 

tive  power  in  children  is  so  great  that  I  have  seen  most 
useful  arms  follow  even  the  worst  injuries  of  this  nature. 

Treatment. — The  treatment  consists  in  placing  the  child 
under  chloroform,   and  remodelling  the  elbow  until   the 
fragments  are  in  good  position.     This  is  done  by  forcibly 
extending  the  arm,  and  then  pressing  the  upper  end  of  the 
ulna  downwards  and  forwards,  whilst  the  forearm  is  being 
pronated  and  flexed  to  an  acute  angle  with  the  upper  arm. 
The  arm  may  then  be  placed  upon  a  Stromeyer's  cushion, 
over  which  a  mackintosh  sheet  has  been  laid.     The  cushion 
is  supported  upon  a  board  projecting  from  the  cot,  or  upon 
a  low,  flat  table  placed  alongside  it,  so  that  the  arm  is 
extended  from  the  body  with  the  elbow  bent  to  a  right 
angle.     An  extension  apparatus  may  be  applied  if  there  is 
any  marked  tendency  to  shortening.    An  evaporating  lotion 
of  Goulard  extract  and  spirit  or  an  ice-bag  is  applied  to 
the  elbow,  and  every  means  is  taken  to  allay  excessive 
inflammation.     A   well-padded  angular   splint  should   be 
applied  to  the  flexed  arm  as  soon   as  the  swelling  has 
somewhat   subsided,  and  gentle  passive   movement  com- 
bined with  massage  should  be  commenced  on  the  twentieth 
day  after  the  injury.     The  split  condyles  of  the  femur  are 
generally  displaced  laterally.    Dr.  Dulles14  has  lately  shown 
that  if  the  forearm  be  fully  flexed  so  that  the  hand  touches 
the  opposite  shoulder,  and  if  at  the  same  time  it  be  semi- 
pronated,    the   radius   and   ulna   hold  the    corresponding 
points  of  the  lower  end  of  the  humerus  in  tolerably  good 
position.     He  therefore  advocates   that   fractures   of   the 
elbow-joint  should  be    treated  in  this  position,   and  this 
may  be  done  by  means  of  flexible  metal  or  felt  splints  care- 
fully moulded  on  to  the  arm. 

Fractures  of  the  Epicondyles. 
Fractures  of  the  epicondyles  are  not  uncommon,  for  they 

N 


178      THE    SURGICAL    DISEASES    OF    CHILDREN 

often  occur  as  a  complication  of  dislocations  at  the  elbow ; 
fractures  on  the  inner  side  of  the  joint  being  rather  more 
frequent  than  those  on  the  outer. 

Cause. — The  accident  is  sometimes  the  result  of  direct 
violence,  and  sometimes  it  is  due  to  indirect  injury.  Mr. 
Jonathan  Hutchinson,  jun.,  points  out  that  separation  of 
the  inner  epicondyle  is  nearly  always  a  clean  separation 
of  the  epiphysis  on  the  inner  side,  and  that  it  often  unites 
by  fibrous  tissue  alone,  but  without  materially  impairing 
the  usefulness  of  the  arm.  The  separated  epitrochlea  is 
drawn  downwards  towards  the  ulna,  and  by  its  pressure 
upon  the  nerve  it  may  give  rise  to  paralysis  of  the  muscles 
supplied  by  the  ulnar,  with  pain  and  limited  movement 
of  sufficient  severity  to  warrant  the  removal  of  the  frag- 
ment of  bone. 

Treatment. — The  limb  may  be  kept  for  three  weeks  in 
a  plaster-of-Paris  splint  moulded  on  to  the  fully  flexed 
elbow. 

Intra-articular  Fracture  of  the  Capitellum. 

Fracture  through  the  external  condyle  of  the  humerus 
is  also  of  frequent  occurrence  in  children,  as  a  result  of 
falls  upon  the  elbow. 

Symptoms. — The  detached  fragment  is  usually  displaced 
a  little  outwards,  and  carries  the  head  of  the  radius  with 
it,  so  that  the  distance  between  the  two  condyles  is  greater 
on  the  affected  than  on  the  sound  side.  Crepitus  is  most 
easily  obtained  by  seizing  the  fractured  condyle  between 
the  finger  and  thumb,  and  lightly  moving  it  upon  the 
humerus. 

Prognosis. — The  prognosis  must  be  guarded  in  these 
cases,  for  the  simple  fracture  is  often  complicated  by 
other  injuries  which  may  be  overlooked  at  the  time  of 
the  injury  owing  to  the  swelling  which  it  causes.     A  good 


INJURIES    OF    BONES  I  /  9 

instance  of  this  occurred  in  a  case  which  I  saw  with  Mr. 
Pick  about  a  year  ago.  A  school-boy,  aged  10,  fell  back- 
wards out  of  a  window,  a  distance  of  fifteen  feet,  into  a 
paved  area,  and  sustained  a  severe  injury  to  his  elbow. 
The  injury  involved  the  joint,  and  when  I  saw  him  three 
months  afterwards  there  was  impaired  movement,  thicken- 
ing at  the  back  of  the  external  condyle,  and  inability  to 
extend  or  fully  to  flex  the  forearm.  A  diagnosis  was  made 
that  the  external  condyle  had  been  fractured,  and  that 
there  was  now  a  forward  dislocation  of  the  radius.  Mr. 
Pick  reduced  the  dislocation  under  chloroform.  The  arm 
was  fixed  at  a  right  angle  in  a  plaster-of -Paris  splint,  and 
six  weeks  later  the  boy  had  good  movement  in  the  joint, 
which  has  since  become  perfect,  for  he  tells  me  that  he 
can  now  ride  and  drive  without  difficulty.  The  capitellum 
is  very  liable  to  remain  as  a  loose  body  in  the  elbow-joint, 
and  it  may  then  lead  to  considerable  impairment  of  move- 
ment and  serious  disorganisation  of  the  elbow,  though  it 
does  not  undergo  necrosis. 

Treatment. — The  arm  should  be  placed  upon  a  rect- 
angular splint  for  a  fortnight,  when  passive  movement 
must  be  commenced,  the  splint  being  replaced  after  each 
stance  until  the  end  of  the  third  week,  when  it  may  be 
laid  aside.  Mr.  Hutchinson  suggests  that  when  the  ex- 
ternal condyle  fails  to  unite,  it  may  be  necessary  to  fix  the 
detached  fragment  by  a  needle,  or  to  peg  it  by  some  other 
means  to  the  surface  from  which  it  has  become  detached, 
the  needle  being  removed  at  the  end  of  three  or  four 
weeks. 

Forearm.    Separation  of  the  Epiphysis  of 
the  Olecranon. 

The  nucleus  for  the  ossification  of  the  olecranon  appears 


l8o      THE    SURGICAL    DISEASES    OF    CHILDREN 

at  the  tenth  year,  and  the  epiphysis  unites  with  the  shaft 
about  the  seventeenth  year. 

^Etiology. — This  injury  is  generally  the  result  of 
direct  violence. 

Symptoms. — The  symptoms  are  semiflexion  with  loss 
of  power  to  extend  the  arm,  great  effusion  into  the  elbow- 
joint,  and  a  more  or  less  marked  gap  at  the  back  of  the 
elbow. 

Prognosis. — The  prognosis  is  not  good  ;  fibrous  union 
may  result,  or  anchylosis  may  take  place. 

Treatment. — The  treatment  is  the  same  as  for  a  frac- 
tured olecranon.  The  arm  should  be  laid  at  rest  upon  a 
cushion  for  a  week  imtil  the  swelling  has  subsided,  the 
patient  being  kept  in  bed.  A  pad  is  then  placed  above 
the  separated  epiphysis,  and  is  secured  with  a  strip  of 
plaster  in  such  a  manner  as  to  keep  the  two  fragments  in 
apposition,  and  a  plaster-of-Paris  splint  is  applied  to  the 
flexor  aspect  of  the  arm  from  the  axilla  to  the  wrist,  to 
keep  the  arm  fully  extended.  The  plaster  splint  is  left  on 
for  a  fortnight,  and  upon  the  twenty-first  day  from  the 
accident  it  is  removed,  and  the  arm  is  gently  flexed  to  an 
angle  of  100°  to  120°.  A  fresh  splint  is  applied,  and  at  the 
end  of  a  month  or  five  weeks  systematic  passive  move- 
ment of  the  joint  with  massage  of  the  limb  is  commenced. 

Separation  of  the  Upper  Radial  Epiphysis. 

Separation  of  the  upper  epiphysis  of  the  radius  is  rare, 
but  Mr.  Mansell  Moullin  showed  an  example  at  the  Patho- 
logical Society  in  1888.  It  occurred  in  a  boy  of  sixteen, 
whose  arm  was  crushed  by  a  machine. 

The  more  common  injury,  which  is  often  diagnosed  as  a 
separation  of  the  upper  epiphysis,  partakes  more  of  the 
nature  of  a  strain,  and  is  perhaps  due  to  a  partial  dis- 


INJURIES    OF    BONES  l8l 

placement  of  the  head  of  the  radius,  caused  either  by  the 
head  slipping  downwards,  or  to  the  orbicular  ligament 
slipping  upwards.  Its  exact  pathology,  however,  is  un- 
known, but  it  is  considered  more  in  detail  at  page  242. 

The  accident  occurs  in  infants  and  in  young  children 
who  have  been  held  up  or  swung  round  by  their  hands. 
The  forearm  is  painful ;  it  is  held  motionless,  and  is  in- 
capable of  being  completely  extended  or  supinated. 

Free  movement  of  the  arm  is  obtained  by  first  bending 
the  elbow,  and  then  gently  but  completely  supinating  the 
arm.  The  arm  should  be  bandaged  to  an  angular  splint 
for  forty-eight  hours,  and  an  evaporating  lotion  should 
be  applied  to  the  elbow.  Mr.  Jonathan  Hutchinson  has 
pointed  out  that  such  accidents  are  very  likely  to  be 
followed  by  disease  of  the  elbow- joint  in  tuberculous  chil- 
dren, just  as  the  more  severe  forms  of  sprained  elbow  may 
form  the  starting-point  of  an  acute  infective  arthritis. 

Shaft. 

Fractures  of  the  shafts  of  the  radius  and  ulna  are  not 
more  numerous  in  children  than  they  are  in  adults,  nor  do 
they  differ  much  in  their  signs  or  in  their  treatment.  The 
surgeon,  however,  has  to  be  on  his  guard  against  over- 
looking those  cases  in  which  one  or  both  bones  are  broken 
subperiosteally,  or  in  which  they  are  only  bent  or  partially 
fractured,  for  such  injuries  are  accompanied  by  the  pro- 
duction of  as  much  callus  as  though  a  complete  fracture 
had  taken  place.  Dr.  Brossard  has  shown  that  subperio- 
steal fractures  of  the  ulna  are  produced  by  indirect  violence 
applied  when  the  arm  is  adducted,  for  in  this  position  the 
force  is  transmitted  directly  along  the  bone.  It  may  also 
be  produced  by  twisting  the  arm  into  a  condition  of  ex- 
treme supination,  for  the  posterior  surfaces  of  the  two 
bones  are  then  brought  into  such  intimate  contact  that 


1 82      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  ulna  is  bent  backwards.  A  similar  twist  into  exag- 
gerated pronation  may  cause  a  spiral  fracture  of  the  radius. 
The  fracture  is  a  mere  fissure,  and  it  may  be  accompanied 
by  an  incomplete  transverse  fracture,  or  even  by  a  tearing 
away  of  the  lower  epiphysis. 

Symptoms. — The  symptoms  most  to  be  relied  upon  in 
these  cases  of  incomplete  fracture  are  pain  and  swelling 
limited  to  the  seat  of  injury.  They  are  extremely  likely 
to  be  mistaken  for  simple  bruising,  as  there  is  neither 
deformity  nor  undue  movement  of  the  bones. 

Treatment. — Any  deformity  in  the  bones  must  be  ac- 
curately remedied.  The  surgeon  must  be  careful  to  see  that 
the  radius  and  the  ulna  lie  parallel  to  each  other  through- 
out any  prolonged  application  of  splints,  and  that  the 
splints  are  sufficiently  wide  to  prevent  the  bandage  from 
pressing  upon  the  sides  of  the  arm  and  so  squeezing  the 
bones  together,  for  crossed  union  takes  place  very  readily, 
and  little  or  nothing  can  be  done  for  the  relief  of  a  patient 
who  has  two  or  three  inches  of  callus  in  his  interosseous 
space.  The  bandage  over  the  splint  may  be  starched,  but 
a  plaster-of-Paris  splint  had  better  not  be  applied. 

Three  weeks  is  a  sufficient  length  of  time  to  keep  the 
arm  fixed. 

Separation  of  the  Lower  Epiphysis  of  the  Radius. 

etiology. — The  lower  epiphysis  of  the  radius  is  oc- 
casionally separated  by  falls  upon  the  outstretched  hand, 
and  I  think  that,  with  the  increase  of  bicycling,  it 
is  becoming  rather  more  frequent  in  young  adults.  An 
injury  which  in  adults  would  lead  to  a  Colles'  frac- 
ture, leads  in  young  children  to  this  accident,  to  a  dislo- 
cation of  the  radius  and  ulna  backwards  at  the  elbow,  or 
to  a  broken  collar-bone. 


INJURIES    OF    BONES  1 83 

Symptoms. — The  symptoms  of  separation  of  the  lower 
epiphysis  resemble  those  of  the  fracture  immediately  above 
the  articular  surface  of  the  radius,  to  which  English  sur- 
geons give  the  name  of  Colles.  Pronation  and  supination 
of  the  arm  are  impossible  ;  the  radial  border  of  the  forearm 
is  shortened,  and  the  styloid  process  of  the  ulna  is  unduly 
prominent.  The  line  of  separation  sometimes  involves  part 
of  the  shaft  of  the  bone,  so  that  the  crepitus  may  be 
more  obvious  than  is  usually  the  case  in  separation  of  an 
epiphysis. 

Diagnosis. — The  deformity  produced  by  separation  of 
the  lower  radial  epiphysis  is  almost  identical  with  that 
occurring  in  Colles'  fracture.  It  may  be  distinguished, 
however,  by  observing  that  the  outline  of  the  wrist  is 
angular,  whilst  in  fractures  it  is  curved.  The  projection, 
too,  upon  the  palmar  surface  is  more  obvious  after  epiphy- 
seal separation  than  after  a  fracture. 

Prognosis. — The  lower  radial  epiphysis  unites  quickly, 
and  the  repair  is  usually  so  perfect,  that  after  a  few 
months  it  is  difficult  to  identify  the  line  of  separation. 
The  growth  of  the  radius,  however,  may  be  arrested  as  a 
result  of  the  injury  sustained  by  the  growing  line. 

Treatment. — The  deformity  must  first  be  reduced.  A 
Carr's  splint  is  then  applied,  the  fingers  being  confined  for 
the  first  week.  The  splint  should  be  replaced  by  a  plaster- 
of-Paris  mitten  at  the  end  of  three  weeks,  and  this  should 
be  worn  for  a  fortnight. 

Ribs. 

etiology. — Fractures  of  the  ribs  occur  in  children  who 
have  been  run  over,  or  have  sustained  other  serious  hv 
juries,  but  they  are  not  very  frequently  observed.  The 
thorax  is  so  elastic  that  such  fractures  are  only  produced 


184      THE    SURGICAL    DISEASES    OF    CHILDREN 

by  considerable  violence,  and  more  than  one  rib  is  usually 
injured. 

The  prognosis  is  therefore  unsatisfactory,  for  the  injury 
is  often  severe  enough  to  have  implicated  the  lungs,  or 
even  the  heart ;  and  I  have  more  than  once  seen  a  hsemo- 
thorax  produced  within  a  few  hours  after  a  child  has  been 
run  over. 

Symptoms. — The  symptoms  vary  greatly  with  the 
nature  and  extent  of  the  injury,  and  are  more  dependent 
upon  the  complications  than  upon  the  broken  ribs. 

The  Treatment  consists  in  keeping  the  child  in  bed, 
and  treating  the  complications  as  they  arise. 

There  is  a  specimen  in  the  Museum  of  St.  Bartholomew's 
Hospital,  in  which  the  heads  of  the  third,  fourth,  and 
fifth  ribs  are  separated  from  their  necks.  The  patient 
was  a  girl  of  two,  who  was  run  over  by  a  dray.  She  died 
instantly,  and  the  lung  was  found  to  have  two  large  rents 
in  its  posterior  border.  I  hesitate  to  call  this  injury  a 
separation  of  the  costal  epiphyses,  as  the  angular  epi- 
physis for  the  head  of  a  rib  does  not  appear  until  the 
sixteenth  year. 

Diagnosis. — Traumatic  fractures  of  the  ribs  must  not 
be  mistaken  for  broken  ribs  resulting  from  rickets,  or 
more  rarely  from  localized  gummatous  deposits  in  cases  of 
inherited  syphilis.  Such  cases  readily  heal  under  appro- 
priate constitutional  treatment,  aided  by  strapping  applied 
to  one  side  of  the  chest  in  the  ordinary  manner. 

Femur. 

Fractures  of  the  femur  are  of  very  common  occurrence 
in  children,  and  they  may  occur  at  any  part  of  the  bone. 

Upper  End. — Very  obscure  injuries  occur  at  the  upper 
end  of  the  femur,  and  they  often  lead  to  permanent  lame- 
ness.    These  injuries  were  for  many  years  supposed  to  be 


INJURIES    OF    BONES  1 85 

associated  with  separation  of  the  upper  epiphysis.  Several 
surgeons — Dr.  Royal  Whitman  amongst  the  foremost — 
have  recently  brought  forward  good  arguments  to  prove 
that  in  a  certain  proportion  of  these  cases  the  neck  of  the 
femur  itself  is  fractured,  though  there  can  be  no  doubt 
that  the  upper  epiphysis  is  often  separated.  In  some  cases, 
too,  the  fracture  is  only  partial,  and  causes  a  greenstick 
fracture,  which  leads  to  bending  of  the  neck  of  the  bone. 

The  separation  of  the  epiphysis  is  the  result  of  a  sudden 
wrench  or  sprain,  whilst  the  fracture  of  the  neck  is  pro- 
duced earlier  in  life,  and  by  a  less  severe  injury,  as  a  fall 
or  blow. 

Symptoms. — The  symptoms  in  either  case  are  shorten- 
ing of  the  limb,  with  elevation  of  the  great  trochanter 
above  Nt'laton's  line  to  the  extent  of  three-quarters  of  an 
inch.  There  may  be  either  external  rotation  of  the  thigh, 
or  it  may  be  inverted.  There  is  usually  pain  on  movement 
and  some  swelling  about  the  joint,  with  inability  to  use 
the  limb. 

Diagnosis. — These  injuries  may  be  mistaken  for  a 
dislocation  of  the  hip,  if  a  history  of  injury  is  forthcoming  ; 
but  if  the  child  is  only  seen  some  time  afterwards,  the 
symptoms  are  often  attributed  to  hip  disease,  or  to  the 
effects  of  infantile  paralysis.  The  freely  movable  joint, 
the  character  of  the  deformity,  and  the  absence  of  trophic 
disturbance,  should  enable  the  surgeon  to  suspect  the 
nature  of  the  injury  even  in  the  absence  of  any  history 
as  to  its  cause,  but  it  is  generally  impossible  to  ascertain 
its  exact  nature. 

Prognosis. — The  prognosis  is  not  very  good  in  young 
children,  for  the  injury  is  frequently  overlooked  until  the 
patient  learns  to  walk.  An  ununited  fracture  may  be  the 
result  of  this  neglect,  or  the  fragments  may  unite  in  a 
faulty  position.     Permanent  lameness  is  caused,  but  the 


1 86      THE    SURGICAL    DISEASES    OF    CHILDREN 

limb  is  otherwise  serviceable.  Mr.  Tubby  has  lately- 
shown  that  separation  of  the  upper  epiphysis  of  the  femur 
is  most  common  after  the  age  of  fourteen  years ;  that  the 
prognosis  of  union  is  not  better  when  it  occurs  at  this  age, 
but  that,  as  in  younger  patients,  a  serviceable  limb  is 
usually  obtained. 

Treatment. — The  application  of  a  plaster-of-Paris 
splint  to  the  thigh  and  pelvis  gives  satisfactory  results,  if 
the  child  is  seen  soon  after  the  injury.  The  splint  should 
be  put  on  whilst  the  child  is  anaesthetised,  and  extension 
should  be  maintained  until  the  plaster  has  set.  The  splint 
should  include  the  pelvis.  A  Thomas'  splint,  with  exten- 
sion, is  also  a  good  method  of  fixing  the  limb  in  these  cases  ; 
but  slight  abduction  of  the  thigh  must  be  maintained,  so 
that  a  useful  limb  may  result  in  case  anchylosis  of  the  hip 
takes  place. 

Separation  of  the  Great  Trochanter. 

The  great  trochanter  is  sometimes  separated  in  patients 
under  the  age  of  seventeen  years,  and  this  form  of  injury 
must  be  distinguished  from  extra-capsular  fracture  of  the 
neck  of  the  femur,  and  from  dorsal  dislocation  of  the  hip. 

Diagnosis. — The  diagnosis  is  difficult,  for  there  is  no 
shortening  of  the  limb  after  separation  of  this  epiphysis, 
and  the  trochanter  on  the  injured  side  describes  the  same 
arc  when  the  thigh  is  rotated  as  it  does  on  the  sound  side. 
There  is  usually  local  pain,  with  slight  swelling. 

Treatment. — The  treatment  consists  in  the  application 
of  a  Thomas'  hip-splint.  There  seems  to  be  a  special 
liability  to  suppuration,  and  even  to  pyaemia,  after  this 
injury,  so  that  too  favourable  a  prognosis  should  not  be 
given.  The  patient  must  be  kept  in  bed  until  the  surgeon 
has  satisfied  himself  that  sufficiently  firm  union  has  taken 


INJURIES    OF    BONES  1 87 

place,  to  prevent  movement  setting  up  any  inflammatory- 
processes  at  the  seat  of  injury. 

Shaft  of  Femur. 

Fractures  of  the  shaft  of  the  femur  are  common  in  young 
children,  and  are  produced  by  comparatively  slight  vio- 
lence. They  are  more  frequent  in  the  ricketty  than  in  the 
healthy. 

Symptoms. — The  thigh  assumes  such  a  characteristic 
position  that  the  nature  of  the  injury  can  hardly  be 
mistaken  ;  but  the  absence  of  pain  and  the  difficulty  of 
obtaining  crepitus  sometimes  cause  the  fracture  to  be 
overlooked.  It  is  often  nearly  transverse,  and  there  is 
generally  very  little  overlapping  of  the  fragments.  It 
may  be  incomplete,  and  of  the  greenstick  variety. 

Prognosis. — The  prognosis  is  very  good,  for  bony  union 
without  shortening  is  usually  the  result  of  every  rational 
method  of  treatment. 

Treatment. — There  are  many  ways  of  treating  a  broken 
thigh  in  childhood.  The  simplest  is  to  put  the  patient 
upon  a  fracture  bed,  and  to  apply  a  Gooch's  splint,  i.e.  a 
"  kettle-holder,"  to  the  whole  thigh,  securing  it  in  place 
by  webbing  straps.  An  extension  of  two  or  three  pounds, 
or  of  so  great  a  weight  as  is  necessary  to  steady  the 
limb,  is  applied  to  the  leg,  and  this  is  usually  reckoned 
as  a  pound  for  each  year  of  the  child's  age.  The  method 
of  applying  extension  is  identical  with  that  described  at 
page  116,  and  seen  in  fig.  15.  There  is  firm  union  in  three 
weeks,  but  I  prefer  to  keep  the  child  in  a  plaster-of-Paris 
case  for  a  fortnight  after  the  splint  has  been  removed. 
A  plaster  splint  (p.  212),  with  extension,  may  often  be  ap- 
plied with  advantage  from  the  beginning.  A  long  Liston's 
splint,  applied  along  the  uninjured  side,  should  be  used  in 
both  methods  to  compel  the  child  to  lie  straight. 


1 88      THE    SURGICAL    DISEASES    OF    CHILDREN 

Children  who  have  incontinence  of  urine,  very  young 
children,  and  those  who  have  both  thighs  broken,  can 
often  be  treated  satisfactorily  without  any  splint,  by 
keeping  them  flat  upon  their  backs  and  rigging  up  an 
extension  apparatus  consisting  of  a  weight  and  pulley  so 
situated  above  the  bed  that  the  thighs  are  flexed  to  a 
right  angle  with  the  body.  The  method  is  not  well 
adapted  for  private  practice,  however,  and  in  little  girls 
it  sometimes  leads  to  an  attack  of  vaginitis. 

Restless  children,  who  cannot  be  induced  to  lie  straight 
and  flat  by  any  other  means,  are  best  secured  in  a  Bryant's 
or  in  a  double  Thomas'  splint. 

Dr.  Elefson  states  that  he  has  most  successfully  treated 
a  fracture  in  the  upper  part  of  the  thigh  of  a  new-born 
child  by  the  application  of  well-padded  antero-posterior 
splints  of  plaster,  the  thigh  being  fixed  in  complete  flexion 
upon  the  abdomen  for  fifteen  days. 

Separation  of  the  Lower  Epiphysis  of  the  Femur. 

This  is  not  a  very  rare  injury  in  young  people.  It  is 
more  frequent  in  boys  than  in  girls,  and  it  is  most  frequent 
about  the  age  of  sixteen  years. 

etiology. — It  occurs  in  its  simplest  form  and  without 
displacement  as  a  result  of  traction  during  labour,  and 
from  wrenching  the  thigh  during  the  operation  of  manual 
osteoklasia.  A  much  more  severe  form  results  from  acci- 
dents. The  violence  in  these  cases  is  always  very  great, 
and  in  thirteen  out  of  twenty-six  cases  collected  by  Mr. 
Tubby  it  was  produced  by  such  a  wrench  as  might  be 
caused  by  getting  the  leg  entangled  in  a  revolving  wheel. 

Pathology. — The  epiphysis  in  the  more  severe  cases  is 
always  considerably  displaced.  It  may  pass  forwards, — 
which  is  most  usual, — backwards,  or  sideways,  the  exact 


INJURIES    OF    BONES  1 89 

direction  appearing  to  vary  with  the  nature  of  the  injury 
producing  it.  When  the  epiphysis  is  displaced  backwards 
into  the  ham,  or  when  the  end  of  the  shaft  passes  back- 
wards and  the  epiphysis  lies  in  front  of  it,  there  is  a  very 
real  danger  of  pressure  upon  the  main  vessels  and  injury 
to  the  large  nerves  in  the  popliteal  space.  In  such  cases 
the  large  veins  may  become  the  seat  of  infective  throm- 
bosis, gangrene  results,  and  may  lead  to  the  death  of  the 
patient. 

Symptoms. — The  pain  varies  in  intensity  according  to 
the  injury  done  to  the  nerves ;  the  knee  is  generally  semi- 
flexed, and  often  much  swollen.  The  foot  is  everted,  and 
there  may  be  an  inch  or  two  of  shortening.  The  epiphysis 
can  be  felt  in  its  new  position,  and  there  is  undue  lateral 
movement  of  the  leg,  including  the  knee-joint,  with 
obscure  crepitus  in  cases  where  there  is  but  little  dis- 
placement. 

Diagnosis. — The  separation  of  the  epiphysis  must  be 
distinguished  from  dislocation  of  the  knee,  and  from  supra- 
condyloid  fracture  of  the  femur.  The  downward  and  back- 
ward direction  of  the  epiphyseal  line  usually  allows  the 
lower  end  of  the  shaft  to  project  backwards  into  the  popli- 
teal space,  whilst  the  lower  fragment  is  displaced  forwards, 
and  can  readily  be  felt. 

Prognosis. — The  prognosis  in  the  simple  cases  is  good, 
for  perfect  repair  usually  takes  place.  It  is  far  otherwise 
in  the  varieties  which  have  been  the  result  of  severe  vio- 
lence, for  the  injury  may  then  be  compound,  or  the  back- 
ward pressure  may  lead  to  gangrene  from  thrombosis,  or 
to  secondary  haemorrhage  from  pressure  and  ulceration. 

Treatment. — The  treatment  in  the  simple  cases  consists 
in  putting  up  the  limb  in  a  plaster-of-Paris  splint,  with 
the  knee  fully  extended.  The  patient  must  be  anaes- 
thetised when  there  is  displacement,  and   the  epiphysis 


I9O      THE    SURGICAL    DISEASES    OF    CHILDREN 

must  be  accurately  replaced.  This  is  done  by  making 
extension  and  counter-extension  upon  the  leg  and  thigh, 
whilst  the  surgeon  manipulates  the  epiphysis.  The  leg 
is  then  carefully  put  up  in  two  lateral  plaster-of-Paris 
splints,  taking  care  that  the  epiphysis  does  not  become 
displaced.  The  splint  should  be  kept  on  for  a  month,  the 
surgeon  being  on  his  guard  during  the  earlier  period  for 
the  slightest  symptoms  of  complications.  The  femoral 
vein  may  be  ligatured  when  there  is  reason  to  suppose 
•that  it  is  the  seat  of  an  infective  thrombosis  ;  but  in  some 
cases,  and  especially  if  gangrene  result,  amputation  is 
sometimes  unavoidable.  Excision  may  be  required  in  un- 
complicated cases  when  it  is  impossible  to  replace  the 
epiphysis. 

Patella. 

Fractures  of  the  patella  do  not  occur  in  young  children, 
and  in  young  adults  they  present  no  peculiarities  by 
which  to  distinguish  them  from  similar  injuries  in  the 
full  grown. 

Cause. — They  are  usually  the  result  of  direct  violence 
or  of  muscular  action. 

Bones  of  the  Leg. 

Separation  of  the  tubercle  of  the  tibia  may  take  the 
place  of  a  fractured  patella  in  a  child,  and  is  readily  mis- 
taken for  a  broken  knee-cap. 

Treatment. — The  treatment  for  this  injury  consists  in 
the  application  of  a  straight  back-splint  to  the  leg,  which 
is  then  raised  to  an  easy  angle  with  the  body,  in  order  to 
relax  the  quadriceps  muscle.  The  separated  tubercle  may 
be  kept  in  place  by  a  piece  of  strapping,  and  the  leg  must 
be  kept  at  rest  for  six  to  eight  weeks. 


INJURIES    OF    BONES  191 

Shafts  of  Tibia  and  Fibula. 

Fractures  of  the  tibia  and  fibula  are  tolerably  frequent 
in  children,  but  they  are  much  less  common  than  fractures 
of  the  thigh.  They  are  often  compound  in  children  who 
have  been  run  over ;  but  even  the  worst  cases  of  compound 
fracture  of  the  leg  are  usually  amenable  to  conservative 
surgery,  and  it  is  only  in  the  most  exceptional  cases  that 
a  primary  amputation  is  necessary.  The  upper  epiphyses 
of  the  tibia  and  fibula  are  occasionally  separated  by  vio- 
lence, but  fracture  is  most  common  in  the  middle  and 
lower  third  of  the  bones. 

Treatment  by  plaster-of-Paris  splints  usually  ensures 
good  repair  in  three  weeks ;  but  it  should  be  borne  in 
mind  that  non-union  is  more  common  in  the  tibia  than  in 
any  other  bone  in  a  child,  and  the  patient  should  therefore 
be  kept  in  bed,  and  not  allowed  to  sit  with  its  legs 
dangling  from  a  high  chair. 

Lower  Epiphysis  of  the  Tibia. 

The  lower  epiphysis  of  the  tibia  is  occasionally  sepa- 
rated, either  by  direct  traction  during  childbirth  or  by 
a  sprain.  The  periosteum  is  not  necessarily  torn,  and 
the  accident  may  therefore  escape  notice.  The  ordinary 
treatment  for  a  Pott's  fracture  should  be  adopted.  In 
older  children,  separation  of  the  lower  epiphysis  of  the 
tibia  is  often  compound,  and  is  associated  with  a  fracture 
of  the  fibula. 

Metacarpal  Bones. 

Fractures  of  the  metacarpus  are  very  rare  in  children, 
except  as  a  result  of  machine  accidents  in  our  manufac- 
turing towns.  Mr.  Jonathan  Hutchinson,  jun.,  has  recently 
shown  that  many  cases  of  supposed  dislocation  and  fracture 


192      THE    SURGICAL    DISEASES    OF    CHILDREN 

of  the  metacarpal  bones  are  in  reality  separated  epiphyses 
when  the  injury  is  situated  at  the  phalangeal  extremity. 
The  treatment  consists  in  the  application  of  a  well-padded 
Carr's  splint  to  the  forearm,  and  securing  the  fingers  for  a 
fortnight  over  the  end  of  its  transverse  portion. 

Metatarsal  Bones. 

Fractures  of  the  metatarsal  bones  usually  occur  from 
the  foot  being  run  over.  The  pain  and  swelling  are  suf- 
ficient to  confine  the  patient  to  his  bed.  The  foot  should 
be  fixed  in  a  plaster-of-Paris  bandage  as  soon  as  the 
swelling  has  subsided. 


CHAPTER   IX 

CONDITIONS   LEADING   TO   ALTERATIONS 

THAT  REQUIRE  SURGICAL  INTERFERENCE 

IN  BONES   AND   MUSCLES 

ANTERIOR   POLIOMYELITIS. 

Ixfaxtile  paralysis  in  its  acute  stages  usually  comes 
under  the  notice  of  the  physician,  but  a  thorotigh  know- 
ledge of  its  course  and  pathology  is  required  by  the 
surgeon,  on  account  of  the  frequency  with  which  he  is 
called  upon  to  treat  its  more  remote  effects. 

etiology  and  Pathology.  —  The  cause  of  infantile 
paralysis  is  usually  an  acute  and  often  well-localised  inflam- 
mation in  the  multipolar  nerve-cells  of  the  anterior  horn 
of  the  grey  matter  of  the  spinal  cord,  though  there  is  some 
evidence  to  show  that  in  a  few  cases  of  infantile  paralysis 
the  lesion  is  primarily  in  the  brain,  and  more  often  on 
the  right  than  upon  the  left  side.  The  predisposing  and 
exciting  causes  of  the  inflammation  are  quite  unknown 
to  us.  It  is  most  frequently  seen  in  young  children  after 
the  beginning  of  the  teething  period,  but  it  may  occur 
in  young  adults.  The  inflammatory  process  terminates 
in  the  disappearance,  shrivelling,  or  pigmentation  of  the 
affected  cells,  and  in  alterations  of  the  axis  cylinders 
originating  in  them,  leading  to  degenerative  changes  in 
the  voluntary  muscles  supplied  by  them.  The  functions  of 
the  nerve-cells  appear  to  be  largely  trophic,  for  after  their 

193  0 


194      THE    SURGICAL    DISEASES    OF    CHILDREN 

disappearance  the  muscular  fibres  shrink  in  size,  and  the 
contractile  siibstanee  often  disappears  entirely,  so  that  the 
fibrous  elements  alone  remain.  The  bones,  the  tendons, 
and  the  ligaments  also  undergo  similar  atrophic  changes, 
in  part  the  result  of  trophic  disturbances,  but  chiefly 
secondary  to  the  muscular  paralysis,  for  they  are  partly 
due  to  disuse,  partly  to  the  mechanical  causes  produced  by 
the  changes  at  the  joints. 

Symptoms. — The  onset  is  acute,  and  may  be  so  sudden 
that,  as  in  the  case  of  Sir  Walter  Scott,  a  child  who  goes 
to  sleep  in  apparent  health  has  been  known  to  awake 
paralysed.  The  temperature  rises  to  100°  or  102°  F.,  and 
there  is  sometimes  a  twitching  of  the  affected  limbs.  Pain 
is  not  a  prominent  symptom,  and  the  sphincters  are  not 
relaxed.  The  paralysis  is  at  first  more  widely  spread  than 
it  afterwards  proves  itself  to  be.  The  muscles  which  are 
permanently  affected  waste  in  the  course  of  two  or  three- 
weeks,  and  cease  to  respond  to  the  faradic  current,  though 
galvanism  produces  exaggerated  contraction  as  compared 
with  the  sound  side.  This  alteration  in  the  excitability 
of  the  muscles  is  known  as  the  reaction  of  degeneration. 
It  is  of  great  service  in  prognosis,  since  as  a  broad  and 
general  rule  the  muscles  which  give  this  reaction  for  a 
period  of  six  to  nine  months  after  the  onset  of  the  disease, 
will  remain  permanently  paralysed. 

Treatment. — The  general  treatment  to  be  adopted  in 
these  cases,  when  the  acute  symptoms  have  passed  away, 
is  to  keep  the  muscles  in  the  best  condition  to  resume 
their  functions  if  their  nerve  supply  is  regained,  and  at 
the  same  time  to  regulate  the  vascular  supply  to  the  parts, 
and  so  to  prevent,  as  far  as  possible,  the  chilblains  and 
ulceration  which  form  so  troublesome  a  feature  in  limbs 
which  have  been  paralysed  for  long  periods  of  time.  These 
indications  for  treatment  are  met  by  recommending  the 


ARTHRODESIS  195 

parents  to  bathe  the  child  daily  in  a  hot  bath  at  a  tempera- 
ture of  80°  F.  for  ten  to  fifteen  minutes,  and  afterwards 
to  nib  some  lin.  camph.  co.  into  the  affected  part.  The 
surgeon  should  himself  shampoo  the  child  two  or  three 
days  a  week.  Ten-minute ,  applications  of  the  galvanic 
current  for  very  long  periods  of  time  afford  the  most  satis- 
factory method  of  local  treatment.  The  child  must  be 
carefully  educated  to  this  treatment  by  commencing  with 
weak  currents,  and  care  must  be  taken  not  to  fatigue  the 
muscles.  Large  electrodes  render  the  application  less 
painful  than  small  ones,  and  the  positive  pole  should  be 
applied  over  the  affected  part,  as  it  is  less  painful  than  the 
negative  one,  which  can  be  placed  over  the  spine.  A  cur- 
rent of  three  milliamperes  should  be  used  first,  and  may 
be  gradually  strengthened  after  a  few  sittings  to  six.  A 
dozen  contractions  of  the  muscles  is  sufficient  at  first. 

Care  must  also  be  taken  throughout  the  treatment  to 
obviate  deformities,  or  to  prevent  their  increase,  by  the 
use  of  splints  or  light  steel  supports,  for  if  this  be  satisfac- 
torily effected  it  will  save  many  troublesome  operations. 
The  various  forms  of  talipes,  stunted  limbs,  dislocations, 
contracted  and  flail  joints  are  the  most  frequent  results  of 
infantile  paralysis.  Club-foot  must  be  treated  upon  the 
ordinary  principles  by  division  of  the  tendons  or  by  the 
subsequent  application  of  supports.  Carefully  adjusted 
orthopaedic  apparatus  will  prevent  contraction  of  the  joints, 
and  may  assist  a  patient  who  has  a  flail  joint. 

Arthrodesis.  lfi 

Arthrodesis  is  the  operation  performed  to  anchylose  a 
joint  in  order  to  secure  an  orthopaedic  result.  It  was  first 
done  by  Albert,  at  Vienna,  on  July  20th,  1878,  and  it  has 
since  been  repeatedly  performed  in  London  by  Mr.  Howse 
and  Mr.  Jacobson,  and  in  Liverpool  ly  Mr.  Robert  Jones. 


I96      THE    SURGICAL    DISEASES    OF    CHILDREN 

It  is  of  especial  service  in  cases  of  infantile  paralysis  of 
long-standing,  at  the  knee  when  the  limb  is  flail-like,  and 
at  the  ankle  when  there  is  so  much  varus  that  division  of 
the  tendons  and  the  application  of  orthopaedic  apparatus 
have  failed  to  rectify  the  deformity.  It  has  also  been 
recommended  for  the  treatment  of  similar  paralytic  con- 
ditions in  the  arm,  and  in  cases  where  the  paralysis  has 
followed  typhoid  fever  and  variola,  or  has  been  due  to 
neuritis ;  and  von  Winiwarter  has  excised  the  wrist  in  a 
case  of  infantile  paralysis  affecting  the  arm.  Those  who 
have  performed  the  operation  most  frequently  speak  of  it 
in  terms  of  high  praise  ;  but  no  case  has  yet  come  under 
my  care  in  which  I  have  felt  justified  in  departing  from 
the  ordinary  rule  of  amputating  through  the  thigh  for  the 
relief  of  this  condition  when  the  use  of  suitable  apparatus 
has  failed.  The  chilblains,  the  ulcerated  condition  of  the 
skin,  and  the  extreme  degeneration  of  the  muscles  have 
always  led  me  to  think  that  the  artificial  production  of 
an  anchylosed  joint  would  be  of  less  service  to  the  unfortu- 
nate patient  than  removal  of  the  paralysed  limb.  I  shall 
have  no  hesitation,  however,  in  performing  the  operation 
as  soon  as  a  suitable  case  presents  itself. 

In  the  knee  the  transverse  incision  dividing  the  liga- 
mentum  patellse  is  usually  adopted,  whilst  in  the  ankle 
the  anterior  incision  from  one  malleolus  to  the  other 
appears  to  be  preferable  to  the  external  or  internal  lateral, 
or  to  the  posterior  incisions.  The  line  of  incision,  in 
each  instance,  must  be  planned  to  meet  the  requirements 
of  the  case,  care  being  taken  to  suture  the  various  tendons 
and  ligaments  which  have  been  divided  when  the  operation 
is  completed.  The  cartilage  covering  the  articular  sur- 
faces of  the  bones  is  gouged  away,  but  there  is  no  need 
to  remove  the  synovial  membrane.  The  joint  is  fixed  in  a 
plaster-of-Paris  case  for  six  weeks  or  two  months  after  the 


SCURVY  197 

operation  until  the  anchylosis  is  complete,  and  as  the 
joint  is  not  diseased  every  effort  should  be  made  to  secure 
union  by  first  intention,  and  no  drainage-tubes  should  be 
employed.  In  cases  of  flail-leg,  both  the  knee  and  ankle 
joints  may  have  to  be  abolished  before  a  useful  limb  is 
obtained. 

SCURVY. 17 

jEItiology. — Scurvy  is  a  rare  disease,  occurring  at  any 
time  after  a  child  is  four  months  old,  and  most  often 
about  the  age  of  nine  months.  It  appears  to  be  the 
result  of  feeding  children  upon  patent  foods  and  artifici- 
ally sterilised  milk.  It  is  therefore  a  little  more  frequent 
in  the  children  of  well-to-do  parents  than  of  paupers. 

Symptoms. — Scurvy  is  likely  to  be  mistaken  for  the 
subacute  form  of  osteomyelitis,  for  the  stress  of  the  disease 
falls  upon  the  bones.  It  is  not  an  infective  disease,  how- 
ever, and  it  runs  a  widely  different  course.  The  onset  is 
usually  gradual ;  the  child  loses  its  appetite,  it  is  averse 
to  moving,  and  lies  quietly  in  its  cot  with  its  legs  and 
thighs  drawn  up.  Presently  it  becomes  peevish,  and  any 
movement  appears  to  produce  the  greatest  pain.  It  is 
dusky  and  pallid,  and  it  wastes  rapidly.  The  gums  may 
bleed  or  there  may  be  passive  haemorrhages  from  the  nose 
or  beneath  the  skin,  and  yet  it  is  not  a  bleeder,  for  there 
is  no  hereditary  history,  and  the  joints  are  unaffected. 
Sooner  or  later  one  or  more  of  the  limbs  becomes  ex- 
quisitely tender,  and  the  legs  more  often  than  the  arms. 
Examination  of  the  tender  spots  shows  that  in  young 
children  they  are  usually  situated  close  to  the  epiphyses, 
but  in  older  children  they  may  be  at  any  part  of  the 
bone.  The  swelling  gradually  increases  in  size  and  in 
extent,  until  the  whole  bone  may  be  encased  in  a  hard 
cylinder.      This  swelling  may  involve  all   the   bones   in 


I98      THE    SURGICAL    DISEASES    OF    CHILDREN 

both  legs  and  thighs  equally  or  unequally,  or  it  may 
affect  only  a  single  bone.  The  scapulae,  the  bones  of  the 
skull,  and  more  rarely  the  bones  of  the  face,  are  affected 
in  a  similar  manner.  The  skin  is  tense  and  shining,  but 
it  is  generally  pale,  and  does  not  feel  unduly  hot  unless 
the  affected  bone  is  quite  subcutaneous.  There  is  a  vary- 
ing amount  of  oedema.  The  disease  usually  lasts  many 
weeks,  and  during  this  time  the  temperature  is  very 
erratic,  though  it  rarely  rises  above  101°- 102°  F.  Mr. 
Holmes  Spicer  describes  a  sudden  proptosis  as  a  feature  in 
some  of  these  cases,  though  this  symptom  has  not  been 
marked  in  any  of  those  which  have  come  under  my  obser- 
vation ;  whilst  Dr.  Wallis  Ord  has  observed  an  extensive 
subcranial  haemorrhage.  The  protrusion  of  the  eyeball, 
which  is  accompanied  by  puffmess  and  very  slight  staining 
of  the  upper  lid,  soon  becomes  bilateral,  the  ocular  con- 
junctiva either  being  a  little  ecchymosed  or  else  quite  free. 
Spontaneous  fractures  are  peculiarly  liable  to  occur.  The 
fracture  is  either  a  separation  of  the  epiphysis,  or  more 
rarely  it  is  a  true  fracture  through  the  shaft  (fig.  18).  It 
generally  occurs  without  any  marked  symptoms,  and  the 
first  sign  of  its  presence  is  an  everted  and  helpless  limb. 
Dr.  Barlow  says  that  the  sternum,  with  the  adjacent  costal 
cartilages  and  a  small  portion  of  the  contiguous  ribs,  some- 
times appear  to  have  sunk  back  bodily  as  a  result  of  these 
changes ;  but  this  condition  I  have  never  happened  to  see. 
Morbid  Anatomy.— Many  of  the  children  affected  with 
scurvy  die,  and  the  autopsy  reveals  the  presence  of  exten- 
sive extravasations  of  blood  beneath  the  periosteum  of 
the  affected  bones,  as  well  as  an  undue  loosening  of  the 
periosteum  throughout  the  skeleton.  The  swellings  sub- 
side slowly  when  the  child  recovers,  and  the  tenderness 
lessens.  The  power  of  voluntary  movement  is  regained, 
and  the  broken  bones  repair. 


SCURVY  199 

Diagnosis. — The  disease  lias  to  be  distinguished  from 
septic  osteomyelitis,  from  rickets,  from  congenital  syphilis, 
and  from  the  cedematous  condition  into  which  marasmic 
children  sometimes  pass.  Rheumatism,  hip  disease,  sar- 
coma, and  infantile  paralysis  can  hardly  be  mistaken  by 
the  most  careless  observer  for  scurvy. 

The  chronic  nature  of  the  disease  and  the  absence  of 
signs  of  septic  infection  distinguish  scurvy  from  osteo- 
myelitis. The  recurrent  symptoms,  such  as  the  gradual 
onset  in  winter  months,  the  cachexia  and  extreme 
ansemia,  the  marked  languor,  the  sponginess  of  the  gums 
and  foul  breath,  the  pain,  the  ecchymoses  and  the 
haematomata,  will  serve  to  distinguish  scurvy  from  rickets, 
from  rheumatism,  and  most  other  forms  of  disease. 

Treatment. — The  effects  of  treatment  are  very  re- 
markable, and  the  child  often  makes  a  speedy  recovery, 
even  from  the  worst  conditions.  The  diet  suitable  to  the 
age  of  the  patient  should  be  given,  but  in  the  ordinary 
quantity  of  milk  one  lightly  boiled  and  mashed  potato 
should  be  given  in  twenty-four  hours,  the  number  of 
potatoes  being  gradually  increased  if  the  child  relishes 
the  mixture.  The  juice  of  a  quarter  of  a  pound  of  lightly 
cooked  steak  may  also  be  added  to  the  milk.  The  judicious 
administration  of  a  little  raw  meat-juice  is  also  of  the 
greatest  advantage.  This  is  best  made  by  pouring  two 
ounces  of  cold  water  upon  a  quarter  of  a  pound  of  rump- 
steak.  The  beef  must  be  finely  scraped,  and  all  the  fat 
should  be  removed.  The  beef  is  soaked  in  the  water  for 
half  an  hour,  or  until  it  is  white,  and  it  is  occasionally 
stirred  with  a  fork.  The  extract  is  then  strained  off 
through  a  fine  gravy  strainer.  Two  or  three  teaspoonfuls 
are  enough  for  a  chill  of  six  or  seven  months  old.  The 
juice  of  one  orange  should  be  administered  after  each  meal, 
and  the  chill  ought  to   be  taken  out  daily  into  the  open 


200      THE    SURGICAL    DISEASES    OF    CHILDREN 

air  as  soon  as  the  acute  symptoms  have  passed  away.  A 
dessert-spoonful  of  cream  may  be  given  night  and  morn- 
ing, to  be  replaced  by  cod-liver  oil  as  soon  as  the  patient 
can  assimilate  it.  The  tenderness  of  the  limbs  is  best 
alleviated  by  a  wet  compress. 

The  bcal  treatment  adopted  by  my  colleague,  Mr.  Picker- 
ing Pick,  consists  "  in  fixation  and  perfect  rest  of  the 
affected  limbs,  for  it  must  be  borne  in  mind  that  the 
blood  extravasation  is  the  primary  lesion,  and  that  the 
subsequent  fracture  probably  arises  from  some  slight 
degree  of  violence  acting  on  the  weakened  bone,  and 
therefore  every  care  must  be  taken  by  fixing  the  swollen 
limbs  to  prevent  this  accident  taking  place.  Even  after 
fracture  has  occurred,  fixation  is  still  necessary  in  order  to 
keep  the  broken  ends  in  apposition,  and  to  promote  union, 
which  in  cases  that  recover  seems  to  take  place  readily 
and  rapidly,  and  if  attention  be  paid  to  position,  without 
deformity.  The  affected  limbs  should  be  bandaged  with 
soft  flannelette  bandages  in  such  a  manner  as  to  fix  them 
in  a  straight  and  extended  position,  and  the  child  should 
be  laid  upon  a  soft  pillow  to  which  it  can  be  fixed  by  a 
broad  flannel  bandage  passed  over  the  trunk,  and  on 
which  it  can  be  carried  about,  and  even  taken  into  the 
open  air,  with  as  little  movement  to  its  limbs  as  possible." 
Massage  is  useful,  after  the  child  has  recovered,  to 
counteract  the  wasting  of  the  muscles  and  the  stiffness 
of  the  joints. 

Dr.  Colcott  Pox  has  very  kindly  permitted  me  to  copy 
the  annexed  figure  (fig.  18),  showing  the  appearances  of 
the  bones  and  periosteum  in  a  case  of  infantile  scurvy 
which  came  under  his  care  when  he  was  attached  to  the 
Victoria  Hospital  for  Children.  The  specimen  is  in  the 
Museum  of  the  Westminster  Hospital.  The  details  of 
the   case   are   published    in    the    Pathological    tiocittijs 


SCURVY 


201 


Fro.  18. — The  bones  of  the  pelvis  and  lower  extremity,  showing  the  changes 
wnich  occur  in  infantile  scurvy. 

[From  Dr.  Colcolt  Fox's  specimen  in  the  Ifuseum  of  the  Westminster  H'>si>itaK] 


202      THE    SURGICAL    DISEASES    OF    CHILDREN 

Transactions,  vol.  xxxviii.  The  patient  was  a  boy,  aged 
11  months.  He  was  quite  helpless,  and  he  screamed  and 
ssemed  to  be  in  great  distress  when  he  was  touched  or 
when  any  one  approached  his  bed.  The  somewhat  limited 
physical  examination  which  could  be  made,  showed 
amongst  other  things  that  the  carpal  ends  of  the  bones  of 
his  forearms  and  the  head  of  the  right  humerus  were 
enlarged,  whilst  the  tibiae  and  fibulae  were  broken  up  as 
completely  as  if  he  had  been  run  over.  There  were  no 
haemorrhages  into  the  skin.  The  temperature  was 
normal  when  the  child  was  first  seen,  but  it  gradually 
rose  to  104-2°  F. 

The  post-mortem  examination  showed  that  the  right 
humerus  was  fractured  through  the  middle  third,  its 
upper  epiphysis  was  widely  separated  by  blood-clot,  and 
the  periosteum  was  completely  stripped  off  the  shaft  in  its 
whole  length  by  an  effusion  of  blood.  The  left  humerus, 
the  bones  of  the  left  forearm,  and  the  scapulae  were  un- 
affected. Both  ilia  were  unduly  soft  and  yielding,  the 
cancellous  tissue  of  the  right  was  blood-stained,  and  the 
periosteum  was  separated  by  haemorrhage.  The  crest  of 
the  left  ilium  was  loosened.  The  periosteum  of  the  right 
femur  was  completely  stripped  off  by  a  layer  of  extra- 
vasated  blood,  and  there  was  a  rather  irregular  oblique 
fracture  of  the  lower  end  of  the  shaft  nearly  on  a  level 
with  the  epiphyseal  line,  the  ragged  ends  of  the  frag- 
ments being  separated  by  clot.  The  right  tibia  was 
stripped  of  periosteum,  had  both  epiphyses  completely 
detached,  with  irregular  splintering  of  the  ends,  and  a 
comminuted  fracture  of  the  centre  of  the  shaft.  The 
right  fibula  was  in  a  similar  condition  ;  and  with  regard  to 
the  bones  of  the  left  extremity,  the  lesions  corresponded 
exactly  with  those  on  the  right  side. 

The  earliest  indication  of  tenderness  in  the  bones  began 


RICKETS  20; 


J 


two  mouths  before  the  child  was  seen,  though  it  had  been 
ailiuc:  for  six  mouths. 


o 


RICKETS. 

The  deformities  resulting  from  rickets  are  constantly- 
brought  to  the  surgeou  to  be  remedied,  and  from  his  point 
of  view  rickets  connotes  alterations  in  the  bony  and  liga- 
mentous structures  of  the  body. 

^Etiology. — The  cause  of  the  disease  is  unknown,  but 
it  often  occurs  in  children  fed  on  patent  foods  and  in  those 
who  are  suckled  for  long  periods  of  time  by  mothers  who 
have  been  repeatedly  pregnant  at  short  intervals.  It 
appears  to  be  due  to  the  failure  of  the  system  to  assimi- 
late certain  substances,  either  because  they  are  absent 
from  the  child's  food,  or  because  when  present  the  digestive 
tract  does  not  absorb  them,  or  the  tissues  refuse  to  make 
use  of  them.  We  do  not  yet  know  what  these  substances 
are  ;  some  pathologists  hold  that  the  disease  is  due  to  the 
defective  assimilation  of  fat,  and  others  that  the  absorption 
of  lime  is  wanting.  The  first  symptoms  of  rickets  gene- 
rally appear  during  the  teething  period  ;  they  may  appear 
for  the  first  time  in  a  girl  at  puberty. 

Symptoms. — The  intestinal  symptoms  are  usually  the 
first  to  appear.  The  child  has  colic  and  a  tumid  belly  ;  it 
passes  more  water  than  usual,  and  the  urine  is  loaded  with 
phosphates.  It  sleeps  badly,  and  is  restless,  often  pre- 
ferring the  nurse's  arms  to  its  cot.  This  no  doubt  is  asso- 
ciated with  the  tendency  to  cranio-tabes,  which  is  so 
marked  a  sign  in  many  cases. 

Symptoms  of  an  unstable  nervous  system  also  show 
themselves  in  convulsions,  attacks  of  laryngismus  strid- 
ulus or  its  modified  form,  when  the  child  has  "  fits  of  hold- 
ing its  breath."  There  is  often  great  vascular  dilation 
coupled  with  profuse  sweating  of  the  head  during  sleep,  or 


204      THE    SURGICAL    DISEASES    OF    CHILDREN 

as  a  result  of  excitement,  and  there  is  often  bony  as  well 
as  cutaneous  hyperesthesia.  The  milk  teeth  are  late  in 
making  their  appearance,  and  if  the  child  has  begun  to 
walk  it  ceases  to  do  so — "goes  off  its  feet,"  the  mother 
will  say  ;  why,  we  do  not  know  ;  perhaps  it  is  the  result  of 
general  debility ;  perhaps,  as  Dr.  Lee  suggests,  it  is  due  to 
paresis  from  nerve  starvation.  This  paresis  is  sometimes 
so  marked  that  it  may  be  mistaken  for  a  case  of  pseudo- 
hypertrophic paralysis. 

Pathology. — Rickets  produces  characteristic  changes  in 
the  bones  and  in  the  ligaments  which  are  of  great  interest 
to  the  surgeon,  for  they  lead  to  numerous  changes  requir- 
ing operative  measures  for  their  relief.  The  early  bone 
changes  are  connected  with  an  imperfect  formation  and 
consolidation  of  the  bone,  both  in  the  shafts  and  at  the 
epiphyses.  The  line  of  calcified  cartilage  at  the  epiphysis 
becomes  much  thicker  than  it  should  be,  and  as  the  bone 
increases  in  length,  long  lines  of  cartilage-cells  with  im- 
perfectly calcified  capsules  are  left  behind  in  the  bone,  and 
so  appear  to  dip  downwards  from  the  wide  epiphyseal  line 
into  the  newly  formed  bone.  The  new  bone  is  imperfectly 
formed,  its  tissue  is  loose  and  spongy,  and  a  process  of 
absorption  takes  place  in  it  leading  to  the  formation  of 
spaces  filled  with  abnormal  marrow.  The  same  changes 
take  place  beneath  the  periosteum  of  the  shaft,  and  the 
bone  has  its  constitution  so  radically  altered  that  it  be- 
comes soft  and  pliable,  whilst  at  the  same  time  the 
epiphyseal  line  is  so  much  thickened  as  in  itself  to  give 
rise  to  a  deformity. 

Course. — These  changes  in  the  bone  lead,  after  a  longer 
or  shorter  period,  to  alterations  in  the  skeleton  which  are 
liable  to  become  permanent.  The  head  becomes  square, 
its  crown  depressed,  and  the  fontanelle  is  not  closed  by  the 
fifteenth  or  sixteenth  month,  as  it  should  be  in  a  healthy 


RICKETS  205 

child.  The  face  has  the  ill-developed  appearance  so  often 
seen  in  the  factory  hands  of  our  large  towns ;  the  teeth 
are  cut  late,  and  appear  at  long  intervals,  they  are 
often  notched  and  soon  become  carious.  They  are  mis- 
placed, for  the  jaws  are  malformed.  The  vertebral  column 
becomes  altered  in  shape,  partly  owing  to  changes  in  the 
bones,  and  partly  owing  to  yielding  of  the  ligaments,  so 
that  various  forms  of  curvature  are  produced,  often  antero- 
posteriorly,  sometimes  laterally  with  concomitant  altera- 
tions in  the  thorax.  The  spinal  column  may  be  curved 
both  laterally  and  antero-posteriorly.  The  primary  curve 
in  the  ricketty  lateral  curvature  is  more  often  to  the  left 
than  to  the  right.  The  pelvis  is  so  altered  that  there  are 
important  modifications  in  the  length  of  its  diameters,  a 
change  of  great  importance  in  the  female.  The  long  bones, 
including  the  clavicle,  become  bent  in  various  directions, 
usually  in  that  of  their  normal  curves.  They  break  as 
a  result  of  any  slight  violence,  they  may  become  curiously 
twisted,  or  their  epiphyses  may  separate.  Alterations 
also  take  place  at  the  knee-joint  leading  to  one  form  of 
genu  valgum,  and  in  the  spine  causing  lateral  curvature. 
These  conditions  are  more  fully  described  on  pages  207 
and  216. 

Sooner  or  later,  if  the  child  survives  the  diarrhoea,  and 
does  not  die  from  bronchial  catarrh  passing  into  bronchitis 
or  with  cerebral  symptoms,  progressive  changes  take  the 
place  of  the  retrogressive  changes  in  the  tissues.  The 
bones,  at  first  softer,  now  become  harder  than  usual.  Those 
which  have  been  bent  acquire  a  buttress  along  their  cor- 
cave  surfaces  by  the  condensation  of  the  newly  formed 
inflammatory  products,  and  the  bone  itself  shares  in  the 
S3lerosis.  The  epiphyses  unite,  and  leave  dense  .and  stunted 
bones  which  are  permanently  deformed.  The  method  by 
which  these  changes  are  brought  about  are  as  yet  only 


206      THE    SURGICAL    DISEASES    OF    CHILDREN 

imperfectly  known.    Their  study  would  well  repay  any  one 
who  chose  to  devote  himself  to  the  subject. 

Diagnosis. — Rickets  has  to  be  distinguished  from  many 
forms  of  digestive  and  nervous  disturbances,  from  tuber- 
culous, syphilitic,  and  scorbutic  affections  of  the  bones,  and 
from  simple  marasmus.  When  it  affects  the  spine,  it  is 
particularly  likely  to  be  mistaken  for  caries.  The  curva- 
ture in  rickets  is  less  persistent,  and  is  abolished  by  exten- 
sion of  the  trunk  (see  fig.  9,  p.  79).  The  muscular  rigidity 
is  less,  and  not  so  lasting ;  the  pain  is  less  acute,  and  it 
does  not  occur  in  paroxysms ;  but  the  child  is  peevish,  and 
has  not  the  intervals  of  comparative  happiness  which  mark 
the  course  of  Pott's  disease. 

Treatment. — The  treatment  of  rickets  is  constitutional 
for  the  improvement  of  the  general  health,  and  local  for 
the  cure  of  the  deformities.  The  geuei'al  treatment  of 
rickets  resalves  itself  into  doses  of  rhubarb  and  soda  for 
the  purpose  of  improving  the  child's  digestive  powers.  It 
should  be  fed  at  regular  and  stated  intervals.  Starchy 
foods,  in  the  form  of  corn-flour  and  milk-puddings,  are  to 
be  given  in  small  quantities  at  a  time.  Fats  in  some  cheap 
form,  as  margarine,  suet,  dripping,  and  frizzled  bacon  or 
sardine  oil,  are  often  palatable  when  the  more  expensive 
forms  are  not  available  or  are  not  relished.  The  adminis- 
tration of  small  doses  of  cod-liver  oil  is  advisable  after 
each  meal.  It  may  be  given  in  combination  with  minute 
proportions  of  phosphorus,  either  as  phosphates  or  as  the 
element  itself,  Tig  of  a  grain  being  a  full  dose  for  a  child 
of  two  years  old.  Neither  drug  should  be  persisted  iu 
if  it  is  found  to  increase  the  digestive  disturbances  to 
which  the  child  is  subject.  Plenty  of  milk  should  be 
given,  and  cream  diluted  with  water  is  often  taken 
greedily.  The  child  must  be  kept  under  the  best  hygienic 
conditions,  and  the  patient  is  easily  kept  warm  at  night, 


KNOCK-KNEE  20J 

when  he  is  apt  to  catch  cold  from  throwing  off  the  bed- 
clothes, by  making  him  sleep  in  loose  flannel  pyjamas  pro- 
vided with  feet.  He  should  be  douched  every  morning  in  a 
tepid  bath  of  salt  water,  if  this  proceeding  is  followed  by  a 
good  reaction,  and  he  should  have  plenty  of  fresh  air  and 
good  food.  Care  must  be  taken  to  prevent  any  exaggera- 
tion in  the  tendency  to  curvature  of  the  bones  or  spine 
by  not  allowing  him  to  assume  improper  positions,  and  the 
child's  legs  may  be  strengthened  by  the  judicious  applica- 
tion of  light  and  jointed  steel  supports  passing  into  the  sole 
of  the  boot  and  along  the  outside  of  the  leg  to  a  pelvic 
band  (fig.  19).  These  supports  are  especially  indicated  in 
children  from  one  to  three  years  of  age,  for  operative 
measures  are  not  generally  required  until  the  bones  have 
become  consolidated  in  their  faulty  positions.  The  opera- 
tive treatment  is  considered  in  the  next  section. 

KNOCK-KNEE. 18 

etiology. — Genii  valgum,  or  knock-knee,  is  one  of  the 
commonest  of  a  group  of  deformities  caused  by  rickets, 
though  the  condition  is  acquired  later  in  life  as  a  result 
of  various  ligamentous  and  muscular  changes.  Ricketty 
knock-knee  is  bilateral,  whilst  the  acquired  form  is  gene- 
rally unilateral.  The  ricketty  form  is  the  result  of 
changes  taking  place  at  the  lower  end  of  the  femur, 
combined  with  some  curving  of  the  shaft  of  the  femur 
or  tibia.  Sir  George  Humphrey  has  recently  and  ably 
defended  the  thesis  that  the  condition  is  due  to  stunt- 
ing of  the  outer  condyloid  part  of  the  femur,  due  to  the 
fact  that  it  is  the  weight-bearing  portion  of  the  bone. 
.Most  pathologists  attribute  it  to  undue  growth  of  the 
internal  condyloid  portion  of  the  femur,  and  they  are  no 
doubt  partially  correct.  The  ligaments  of  the  joint  are 
scarcely  altered.     Knock-knee  in  older  subjects  is,  with 


208      THE    SURGICAL    DISEASES    OF    CHILDREN 

or  without  curvature  of  the  lower  part  of  the  shaft  of 
the  femur,  undoubtedly  due  to  changes  in  the  lateral  and 
intrinsic  ligaments  of  the  knee,  and  at  a  later  period  in 
the  muscles,  the  bones  only  becoming  secondarily  modified 
in  very  long-standing  cases.  Flat-foot  is  sometimes  a 
predisposing  cause. 

Symptoms.  —  Bilateral  knock-knee  is  noticed  in 
children  who  are  manifestly  ricketty  soon  after  they  have 
learnt  to  walk.  The  signs  are  more  obvious  than  the 
symptoms.  If  the  knees  are  made  to  touch  each  other 
when  the  child  is  lying  down,  it  will  be  found  that  the 
ankles  are  widely  separated,  and  the  interval  between  the 
two  internal  malleoli  is  the  measure  of  the  deformity.  The 
lateral  movement  in  the  knee  is  too  free,  owing  to  the 
stunted  growth  of  the  outer  condyle,  and  there  is  an 
exaggeration  in  the  normal  movements  of  the  joint.  There 
is  usually  a  well-marked  projection  of  bone  upon  the  inner 
side  of  the  joint,  partly  due  to  the  internal  condyle  of  the 
femur,  and  partly  to  the  upper  end  of  the  tibia.  This 
prominence  disappears  when  the  knee  is  flexed.  The 
patella  is  displaced  outwards  to  a  greater  or  less  extent. 

Treatment. — The  treatment  of  genu  valgum  and 
ricketty  deformity  of  the  legs  by  operative  measures  is  of 
daily  occurrence.  It  is  not  necessary,  however,  to  adopt  it 
in  every  case,  for  in  young  children  the  bones  are  often 
sufficiently  pliable  to  enable  the  deformity  to  be  gradually 
remedied  by  the  application  of  suitable  apparatus  (see 
fig.  19),  whilst  with  better-class  patients  a  pony  may  be 
recommended  for  the  boys  to  ride.  In  the  later  stages  of 
rickets  when  the  bones  are  dense,  and  in  the  very  extreme 
cases  of  genu  valgum,  an  operation  is  imperatively  called 
for,  and  it  is  only  wasted  time  to  delay  its  performance. 
The  operations  in  ordinary  use  are  those  of  osteoklasia  and 
osteotomy. 


OSTEOKLASIA 


209 


Osteoklasia  is  of  two  kinds,  either  by  forcible  straight- 
ening,18 or  by  means  of  the  osteoclast.  Mr.  R.  W.  Murray 
has  performed  the  operation  of  forcible  straightening  no 
less  than  311  times  in  1893,  and  it  was  extensively  per- 
formed by  the  late  Mr.  Walter  Pye.  It  has  been  largely 
employed  by  the  French  and  Italian  surgeons.     I   have 


Fig.  19.— Outside  splint  with  pelvic  band  and  lateral  attachments  for  use  in 
the  slighter  forms  of  knock-Unee. 

adopted  the  treatment  in  a  few  cases,  and  always  for 
children  under  8  or  9  years  of  age  whose  bones  seemed 
pliable,  but  I  have  never  been  able  to  acquire  the  knack  of 
cracking  the  denser  bones  without  using  what  I  consider 
to  be  an  undue  amount  of  force,  and  I  have  therefore  of 
late  years  given  it  up  in  favour  of  osteotomy. 

The  technique  of  forcible  straightening  is  easy  to  de- 

P 


2IO      THE    SURGICAL    DISEASES    OF    CHILDREN 

scribe,  but  there  is  a  certain  knack  of  breaking  even  the 
most  compact  bone,  which  is  only  acquired  by  practice  and 
cannot  be  communicated  by  words.  In  an  anterior  curva- 
ture of  the  tibia  the  bone  is  fractured  laterally,  and  it 
may  be  necessary  to  divide  the  tendo  Achillis  to  enable 
the  lower  fragment  to  be  brought  into  good  position.  In 
forcibly  straightening  a  knock-knee,  the  thigh  is  grasped 
firmly  about  two  inches  above  the  patella,  and  the  surgeon, 
using  his  index  finger  supported  by  his  other  fingers  as  a 
fulcrum,  holds  the  thigh  perfectly  steady  and  gradually 
straightens  the  limb  till  the  bone  yields,  the  knee-joint 
being  kept  over-extended  the  whole  time.  The  usual  point 
of  fracture  it  is  stated  almost  invariably  takes  place  where 
the  lower  end  of  the  femur  joins  the  shaft,  and  quite  an 
inch  above  the  epiphyseal  line,  so  that  there  is  no  danger 
of  injuring  the  epiphysis,  and  so  of  interfering  with  the 
subsequent  growth  of  the  limbs.  Barbarin,  however,  has 
recently  devoted  his  attention  to  the  exact  seat  of  rupture 
in  cases  of  forcible  osteoklasia,  and  he  has  demonstrated  by 
the  examination  of  specimens  that  in  some  cases  the  line 
of  the  epiphysis  is  actually  involved.  The  leg  and  thigh 
should  be  put  up  in  a  plaster  bandage  for  three  weeks  after 
the  operation. 

Ricketty  bones  are  sometimes  broken  by  means  of  the 
osteoclast.  I  have  often  seen  the  method  employed,  but  it 
has  always  seemed  to  me  to  be  barbarous,  and  to  be  a  con- 
fession of  weakness  on  the  part  of  the  surgeon  that  he  had 
not  perfect  trust  in  his  ability  to  keep  the  wound  aseptic. 

It  is  a  method  which  might  perhaps  be  recommended 
in  private  cases,  where  the  sanitary  conditions  and 
surroundings  were  not  all  that  could  be  desired ;  but  even 
in  such  cases  it  would  be  unsatisfactory,  on  account  of  the 
after-pain,  which  is  greater  than  that  occurring  after 
forcible  straightening  or  after  osteotomy. 


OSTEOTOMY  2  I  I 

Osteotomy  is  either  linear  or  cuneiform.  Linear  osteo- 
tomy is  performed  for  genu  valgum,  ordinary  ricketty 
curvature,  and  at  the  neck  of  the  femur  in  cases  of 
anchylosis  in  bad  position  as  a  result  of  hip  disease  (see 
p.  124).  Cuneiform  osteotomy  consists  in  removing  a 
wedge  from  the  tibia  for  the  cure  of  ricketty  bowed  legs 
when  the  curvature  is  directed  forwards. 

(1)  Linear  Osteotomy. — Some  modification  of  Macewen's 
operation  is  usually  performed  for  the  cure  of  the  more  ad- 
vanced forms  of  knock-knee  in  children  over  five  years  of 
age.  The  limb  is  rendered  aseptic  in  the  usual  manner,  on 
the  day  before  the  operation,  and  is  wrapped  in  a  gauze 
dressing.  An  anaesthetic  is  given  on  the  following  day, 
the  dressings  are  removed,  and  the  skin  of  the  knee  and 
thigh  are  thoroughly  washed  with  perchloride  of  mercury 
solution  1  in  1000.  The  leg  is  slightly  flexed  and  laid  upon 
its  outer  side  on  a  wooden  block  covered  with  absorbent 
cotton  wool  freshly  wrung  out  of  the  solution  of  per- 
chloride of  mercury.  The  operator  then  feels  for  the 
well-defined  inner  border  of  the  femur,  and  after  making 
the  skin  tense  with  the  finger  and  thumb  of  his  left  hand, 
enters  his  scalpel  longitudinally  about  half  an  inch  above 
the  upper  border  of  the  internal  condyle.  The  scalpel  is 
carried  on  until  it  reaches  the  bone  after  the  periosteum 
has  been  divided,  and  an  incision  is  made  of  sufficient 
length  to  allow  the  osteotome  to  be  entered.  The  scalpel 
is  now  transferred  to  the  left  hand  without  withdrawing 
it  from  the  wound  ;  the  osteotome,  an  instrument  whose 
cutting  edge  is  bevelled  upon  both  sides  and  blunt 
laterally,  is  then  taken  up  and  is  passed  into  the  wound 
along  the  side  of  the  scalpel,  until  its  edge  is  felt  to  be  in 
contact  with  the  bone.  The  scalpel  is  immediately  with- 
drawn and  a  pledget  of  lint  soaked  in  the  antiseptic  lotion 
is  held  round  the  osteotome  at  its  point  of  entrance  to 


212      THE    SURGICAL    DISEASES    OF    CHILDREN 

prevent  the  access  of  air  to  the  wound.  The  osteotome  is 
next  turned  transversely,  so  that  its  cutting  edge  lies 
across  the  bone  at  right  angles  to  the  shaft.  Its  head  is 
then  repeatedly  struck  with  a  wooden  mallet,  the  osteotome 
being  held  firmly  in  the  fingers  of  the  left  hand,  whilst  it 
is  steadied  by  the  extended  thumb,  until  it  is  felt  to  have 
entered  the  bone  for  some  distance. 

Bones  vary  greatly  in  their  density,  so  that  the  force 
used  must  be  regulated  in  accordance  with  the  require- 
ments of  the  individual  case.  The  surgeon  soon  learns  to 
distinguish  when  he  has  passed  through  the  compact  tissue 
on  the  inner  side  of  the  bone,  and  has  come  to  the  can- 
cellous tissue  in  the  centre.  He  should  withdraw  his 
osteotome  as  soon  as  he  meets  with  the  resistance  offered 
by  the  compact  tissue  on  the  outer  side.  An  endeavour  is 
then  made  to  fracture  the  bone  by  seizing  the  leg  in  one 
hand  and  the  thigh  in  the  other,  keeping  the  pad  of  wool 
over  the  wound  with  one  thumb.  A  sudden  wrench  is 
usually  enough  to  complete  the  division.  It  should  be  the 
surgeon's  object  not  to  enter  the  osteotome  more  than  once; 
but  if  the  bone  does  not  yield,  it  is  better  to  replace  the 
instrument  than  to  use  an  unjustifiable  amount  of  force  in 
endeavouring  to  fracture  the  bone.  It  is  not  generally 
necessary  to  insert  any  sutures,  as  a  half- inch  skin  incision 
is  amply  sufficient  for  the  entrance  of  the  osteotome,  and 
I  think  it  is  better  not  to  irrigate  the  wound.  The 
wound  is  at  once  dressed  with  a  pad  of  wet  gauze,  and  the 
ordinary  antiseptic  dressings  are  applied. 

A  flannelette  bandage  is  then  applied  from  the  foot,  up 
the  leg  and  over  the  knee,  and  a  plaster  case  is  fitted  from 
just  above  the  ankle  to  the  fork  of  the  thighs.  The  case 
is  usually  made  by  cutting  a  piece  of  ordinary  house  flannel 
of  two  thicknesses  and  placing  a  layer  of  lint  upon  its 
inner  side.     The  shape  is  represented  in  the  diagram  (fig. 


OSTEOTOMY 


213 


20),  the  side  ab  corresponding  to  the  length  of  the  limb, 
and  ac,  bd  to  its  circumference  at  the  thigh  and  ankle 
respectively,  the  piece  below  bd  being  the  foot  piece.  The 
inner  lining  of  lint  is  sufficiently  large  to  allow  of  its 
being  wrapped  over  the  edges  of  the  flannel.  The  flannel 
is  saturated  with  plaster-of-Paris  paste  made  by  mixing 
one  pound  of  freshly  burnt  plaster  with  one  pint  of  water, 
the  excess  of  plaster  being  wrung  out  of  the  case.  The 
lining  of  lint  is  then  put  in,  and  the  case  is  bandaged  on 


Fig.  20. — Diagram  of  plaster  case  for  use  after  osteotomy  of  the  femur  for 
genu  valgum,  or  after  a  cuneiform  osteotomy  of  the  tibia. 

to  the  limb.  The  limb  must  be  held  firmly  until  the 
plaster  has  set,  that  is  to  say,  until  it  gives  a  metallic 
ring  upon  being  struck,  and  whilst  it  is  setting  the  thigh 
must  be  pulled  outwards  whilst  the  leg  is  pushed  inwards, 
so  as  to  completely  overcome  the  position  of  knock-knee. 
Much  of  the  after-success  of  the  operation  depends  upon 
the  effectual  performance  of  this  simple  manoeuvre. 

The  dangers  of  the  operation  in  children  are  not  great ; 
and  although  I  have  performed   it  many  dozen  times,  I 


214      THE    SURGICAL    DISEASES    OF    CHILDREN 

have  never  yet  got  into  serious  trouble.  Sometimes  there 
is  sharp  arterial  bleeding  when  the  scalpel  is  entered, 
either  because  the  incision  has  been  made  too  high,  or  from 
the  division  of  some  branch  of  the  anastomotica  magna 
or  superior  internal  articular  branches ;  the  bone  may  be 
unduly  vascular  in  other  cases,  so  that  subsequent  oozing 
may  require  the  dressing  to  be  changed  and  firmer  pressure 
to  be  applied.  The  popliteal  artery  is  not  likely  to  be 
injured  if  a  narrow  osteotome  be  used,  and  its  edge  be 
carried  more  towards  the  front  than  the  back  of  the  bone 
whilst  the  section  is  being  made. 

The  after-treatment  is  of  the  simplest :  the  child  is  kept 
flat  upon  its  back  in  bed  for  three  weeks  without  any 
change  of  dressing,  unless  it  has  been  accidentally  soiled, 
or  unless  the  temperature  rises. 

(2)  Cuneiform  Osteotomy  has  to  be  performed  much  less 
frequently  than  linear  osteotomy,  as  it  is  only  required 
in   the  most  pronounced  cases  of  anterior  bowing  of  the 
leg,  and   when  division  of  the   tendo  Achillis  has  been 
ineffectual  in  allowing  the  curvature  to  be  overcome ;  the 
result   of   the   operation   is,    however,    most   satisfactory, 
as  may  be  seen  in  the  annexed  drawings  (figs.   21  and 
22),   made  from  photographs  of  the  same  patient.      The 
operation  is  performed  with  the  same  antiseptic  precau- 
tions as  in  the  previous  case.    A  two-inch  incision  is  made 
immediately  to  the  inner  side  of  the  shin  at  the  point  of 
its  greatest  convexity.     The  periosteum  is  divided,  and  is 
carefully  separated  from  the  inner  and  outer  borders  of  the 
tibia,  transverse  incisions  being  made  through  it  at  the 
upper  and  lower  margins  of  the  wound.     The  periosteum, 
and  with  it  the  skin  and  tissues  covering  the  shin,  are 
then  retracted  upon  either  side.     A  bone  chisel  is  applied 
with  the  flat  side  to  the  upper  part  of  the  tibia,  and  is 
made  to  divide  the  anterior  and  the  inner  surfaces  of  the 


OSTEOTOMY 


215 


bone  by  repeated  blows  upon  its  head  with,  a  mallet  until 
the  medullary  cavity  is  reacted.  The  bone  is  again  cut 
at  the  lower  border  of  the  wound,  and  a  wedge  can  then 
be  extracted  with  a  strong  elevator.  The  remainder  of 
the  tibia  and  the  fibula  are  then  fractured  forcibly,  and 
the  leg  is  brought  into  good  position  ;  or,  if  this  cannot 
be  done,  more  bone  is  removed  until  the  surgeon  is  satisfied 


Fig.  21.— Ricketty  deformity  of  the  tibia.  Fig.  22.— Leas  of  the  same  patient 

after   the   performance  of    cuneiform 
osteotomy. 
[From  a  patient  who  was  subjected  to  cuneiform  osteotomy.] 

with  the  result.  The  wound  is  then  thoroughly  flushed 
with  a  5  per  cent,  solution  of  boric  acid,  any  sharp  spiculse 
of  bone  are  removed  with  cutting  forceps,  the  edges  of'  the 
periosteum  are  brought  together,  but  it  is  unnecessary  to 
suture  them,  and  the  wound  is  closed  with  horsehair 
sutures.  Antiseptic  dressings  are  applied,  and  the  leg  is 
put  into  a  plaster  case  (fig.  20)  and  is  held  straight  until 


2l6      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  plaster  sets.  The  child  is  kept  in  bed  for  about  three 
weeks.  Union  takes  place  by  first  intention  if  care  has 
been  taken  to  perform  the  operation  subperiosteally,  not 
to  bruise  the  periosteum,  and  to  keep  the  wound  aseptic. 
The  only  complication  likely  to  occur  is  a  sharp  haemor- 
rhage from  the  nutrient  artery  of  the  tibia  ;  this  stops, 
however,  as  soon  as  the  bone  is  completely  fractured. 

SCOLIOSIS,  OR  LATERAL  CURVATURE. 

etiology. — Lateral  curvature  is  essentially  a  disease 
of  young  adult  life,  and  is  more  common  in  girls  than  in 
boys.  It  is  due  to  a  variety  of  causes.  In  a  few  cases  it 
is  congenital,  in  others  it  is  supposed  to  be  the  result  of 
habit,  but  on  inconclusive  grounds.  It  is  often  a  manifes- 
tation of  rickets,  but  it  is  most  frequently  secondary  to 
alterations  in  the  long  axis  of  the  body,  and  so  is  com- 
pensatory to  other  conditions.  Under  this  head  come  the 
paralytic  form,  lateral  curvature  associated  with  paralytic 
affections  involving  the  muscles  of  one  side  of  the  back, 
that  seen  in  tuberculous  affections  of  the  vertebrae,  and 
of  the  hip,  or  after  knock-knee,  or  in  deformities  of  the 
pelvis  and  hip,  in  wryneck,  and  as  a  result  of  a  cured 
empyema.  Rickets  is  practically  the  only  cause  of  lateral 
curvature  during  the  first  few  years  of  a  child's  life ;  and 
the  primary  curve  in  these  cases  is  a  little  more  common 
upon  the  left  than  upon  the  right  side. 

Morbid  Anatomy. — In  a  typical  case  of  lateral  curva- 
ture the  spinal  column  presents  a  marked  curvature  to  the 
right  in  the  dorsal  region,  and  a  compensating  curve  to 
the  left  in  the  lower  dorsal  and  lumbar  region.  The  curve, 
however,  varies  as  greatly  in  its  position  as  it  does  in  its 
extent,  and  the  primary  curve  may  be  to  the  left,  the 
secondary   curve   being  upon  the   right.      The   vertebras 


LATERAL    CURVATURE  2  I  7 

themselves  become  greatly  modified,  for  in  the  more  severe 
cases  their  anterior  surfaces  face  towards  the  convexity 
of  the  curve,  whilst  the  spinous  processes  maintain  their 
normal  relations  better,  so  that  the  curvature  is  much 
more  marked  anteriorly  than  posteriorly.  There  is  con- 
siderable doubt  as  to  the  exact  nature  of  the  torsion  in 
these  cases,  most  pathologists  maintaining  that  it  is  due 
to  modifications  in  the  vertebrae  themselves,  whilst  some 
hold  that  it  is  due  to  a  rotation  of  the  vertebral  column  as 
a  whole  ;  and  others  think  that  it  is  only  an  exaggeration 
of  the  tendency  towards  spiral  growth  which  characterises 
so  many  animal  and  vegetable  organisms.  As  a  result  of 
these  changes,  the  transverse  processes  and  the  ribs  on  the 
convex  side  are  separated  from  each  other  and  are  directed 
backwards,  whilst  upon  the  concave  side  of  the  curve  they 
are  crowded  together  and  look  forwards.  The  inter- 
vertebral fibro-cartilages  undergo  similar  changes,  or  they 
become  wedge-shaped,  the  thin  edge  of  the  wedge  being 
directed  towards  the  concavity  of  the  curve,  whilst  the 
ligamenta  subflava  are  shortened  along  the  concavity. 
The  anterior  common  ligament  also  undergoes  considerable 
changes,  but  the  posterior  common  ligament  hardly 
changes  at  all,  even  in  the  most  severe  cases. 

The  thorax  also  becomes  modified,  owing  to  the  changes 
in  the  vertebral  column,  the  net  result  being  an  increase 
in  the  size  of  its  cavity  upon  the  convex  side  and  a  con- 
traction upon  the  concave  side.  In  severe  cases  a  portion 
of  the  thoracic  cavity  actually  lies  behind  the  plane  of  the 
vertebral  spines  upon  the  convex  side  of  the  curve. 

Symptoms. — The  first  symptom  to  be  noticed  is  that 
"  the  shoulder  -  blade  grows  out,"  or  that  the  patient 
carries  one  shoulder,  generally  the  right,  higher  than  the 
other,  or  that  his  right  hip  is  more  prominent  than  his 
left.     In  some  cases  the  right  side  of  the  chest  seems  to 


2l8      THE    SURGICAL    DISEASES    OF    CHILDREN 

be  more  fully  developed  than  the  left.  The  subjective 
symptoms  are  ill-defined,  and  generally  a  sense  of  weak- 
ness is  alone  complained  of,  or  there  may  be  neuralgic 
pains  due  to  pressure  upon  the  spinal  nerves  at  the  inter- 
vertebral foramina.  A  thorough  examination  of  the  spine 
must  be  made  in  all  suspected  cases.  It  will  then  be 
found  that  the  curvature  can  be  classified  into  three 
groups.  The  first,  in  which  there  is  a  simple  weakness 
of  the  back,  and  although  there  is  a  primary  curve,  no 
compensatory  condition  has  yet  been  produced.  In  these 
cases  the  curvature  readily  disappears  when  the  child 
lies  flat,  or  when  it  is  supported  by  placing  the  hands 
under  the  armpits,  or  when  it  is  made  to  bend  forwards. 
In  the  second  stage  the  curvature  is  diminished  when  the 
patient's  vertebral  column  is  supported,  but  it  does  not 
entirely  disappear.  In  the  third  stage  the  curvature  is 
permanent,  and  compensatory  changes  have  taken  place. 
The  third  and  worst  form  of  scoliosis  is  often  accompanied 
by  symptoms  due  to  the  alterations  in  the  thorax.  The 
breathing  is  short,  the  patient  may  be  subject  to  bronchitis 
and  pneumonia,  and  there  may  be  serious  vascular  dis- 
turbances culminating  in  dilatation  of  the  right  ventricle. 
Secondary  changes  in  the  abdominal  and  pelvic  viscera 
are  by  no  means  infrequent. 

Diagnosis. — Scoliosis  is  more  liable  to  be  overlooked 
than  to  be  mistaken  for  any  other  condition.  Pott's 
disease  and  simple  weakness  of  the  spine  are,  however, 
occasionally  assumed  to  be  cases  of  scoliosis.  Weakness 
of  the  spine  practically  presents  the  same  changes  as  the 
first  stage  of  lateral  curvature,  though  the  pathology  is 
not  identical,  for  in  weak  spines  there  is  no  rotation  of 
the  front  of  the  vertebrae.  The  two  conditions  are  dis- 
tinguished from  the  second  stage  of  scoliosis  by  making 
the  patient  bend  downwards  with  the  knees  straight  and 


LATERAL    CURVATURE  219 

the  arms  outstretched  until  the  finger-tips  touch  the 
floor.  The  scoliotic  curve  will  remain,  whilst  the  curvature 
of  weakness  disappears.  In  Pott's  disease  the  curvature 
is  rather  a  deviation  of  the  entire  body  to  one  side  than 
a  sinuous  condition  of  the  vertebral  column.  The  bending 
of  the  trunk  is  usually  towards  the  right  side,  and  it  is 
more  perceptible  when  the  patient  is  looked  at  from  before 
than  from  behind. 

Prognosis. — Scoliosis  varies  greatly  in  the  course 
which  it  pursues.  The  curves  usually  develop  slowly  and 
almost  imperceptibly ;  sometimes,  however,  they  attain 
their  full  development  in  the  course  of  a  few  months,  and 
sometimes  they  remain  stationary.  The  process  generally 
terminates  with  the  cessation  of  bony  growth,  that  is  to 
say  about  the  twenty-second  to  the  twenty-fifth  year. 

Treatment. — The  treatment  is  either  prophylactic  or 
curative,  and  it  should  always  be  causal  if  possible.  Pro- 
phylactic treatment  consists  in  improving  the  general 
health,  in  correcting  faulty  or  unilateral  movements  of  the 
spine,  and  in  strengthening  as  far  as  possible  the  ligaments 
and  muscles  of  the  vertebral  column  by  shampooing,  and 
gymnastics  carried  out  under  intelligent  supervision.  The 
patient  should  be  made  to  rest  in  the  painful  forms  of 
the  disease.  In  the  slighter  forms  she  may  be  directed 
to  lie  flat  upon  her  back  upon  the  floor  or  upon  a  hard, 
firm  couch  for  a  certain  length  of  time  daily,  the  time  to 
be  spent  in  reading  by  holding  her  book  above  her.  Ling's 
system  of  Swedish  gymnastics  may  also  be  tried  with 
good  effect  in  these  slighter  cases,  whilst  in  the  more 
severe  forms  the  patient  should  lie  upon  the  affected  side, 
which  is  supported  in  a  sling  consisting  of  a  broad 
webbing  bandage,  so  adjusted  that  the  weight  of  the  body 
may  serve  to  straighten  the  curves. 

Mechanical  means  must  be  adopted  if    the   curvature 


2  20      THE    SURGICAL    DISEASES    OF    CHILDREN 

progresses  in  spite  of  these  slighter  measures.  The 
appliances  are  manifold,  and  range  from  a  simple  diagonal 
bandage  to  the  most  complex  and  expensive  jackets.  The 
consideration  of  these  forms  of  apparatus  belongs  strictly 
to  orthopsedic  surgery.  The  chief  points  to  be  borne  in 
mind  are  that  they  should  be  as  light  and  as  simple  as  is 
compatible  with  utility,  that  they  should  not  be  employed 
to  the  exclusion  of  other  methods,  and  that  in  every  case 
the  treatment  should  be  carried  out  upon  physiological 
principles,  for  lateral  curvature  is  essentially  an  inter- 
ference with  the  normal  processes  of  growth,  and  is  not  in 
itself  a  disease.  Lorenz  has  recently  advocated  forcible 
straightening  in  advanced  cases  of  lateral  curvature,  with 
the  application  of  a  plaster-of-Paris  jacket  which  is 
capable  of  easy  removal,  and  is  appropriately  padded,  to 
obtain  diagonal  compression  of  the  thorax.  The  jackets 
are  put  on  with  the  body  sufficiently  extended  to  overcome 
the  curvature. 

WRYNECK. 

Torticollis  is  that  condition  in  which  the  head  is  held 
either  permanently  or  intermittently  in  a  condition  of  uni- 
lateral abduction,  the  chin  being  turned  to  the  opposite 
side,  and  being  at  the  same  time  a  little  elevated.  The 
condition  is  congenital  or  acquired,  primary ;  or  a  symptom 
of  some  other  affection. 

Congenital  Wryneck. 

etiology. — The  congenital  form  is  due  to  congenital 
shortening  of  one  sterno-mastoid  muscle,  perhaps  con- 
nected with  defective  development  of  the  cervical  vertebrae, 
with  errors  of  intra-uterine  position,  or  as  Mr.  Grolding- 
Bird  supposes,  with  a  central   brain  lesion — acute  polio- 


WRYNECK  22  1 

encephalitis — akin  to  acute  infantile  paralysis.  It  is  far 
more  frequent  upon  the  right  than  upon  the  left  side, 
and  may  be  associated  with  defective  development  of  one 
side  of  the  face. 

Diagnosis. — The  wryneck  in  its  slightest  forma  is 
often  better  recognised  by  looking  at  the  patient's  reflec- 
tion in  a  mirror  than  by  direct  observation. 

Treatment. — The  treatment  consists  in  dividing  the 
sternal  attachments  of  the  shortened  muscle,  and  the  sub- 
sequent application  of  some  form  of  elastic  apparatus  to 
keep  the  head  straight. 

Acquired  Wryneck. 

etiology. — Acquired  wryneck  may  be  the  result  of 
cicatrisation  after  extensive  burns,  or  from  the  contraction 
of  the  fasciae  beneath  the  skin  as  a  result  of  various  in- 
flammatory conditions.  '  It  is  occasionally  produced  by 
primary  contraction  of  the  fasciae  of  the  same  character 
as  Dupuytren's  contraction  of  the  palmar  fascia,  or  it  may 
be  a  purely  muscular  change  connected  either  mainly  with 
the  sterno-mastoid  itself,  or  less  frequently  with  the 
platysma.  The  muscular  contraction  may  be  due  to  local 
causes  affecting  the  muscle  itself,  or  it  may  be  due  to 
nerve  injury,  to  nerve  irritation,  or  to  inflammatory  con- 
ditions of  the  parts  near  the  muscle,  as  in  cases  of 
enlarged  glands.  Acquired  wryneck  due  to  muscular 
spasm  is  sometimes  a  sequel  of  typhoid,  scarlet  fever, 
diphtheria,  or  malaria.  New  growths  in  the  sterno-mas- 
toid and  injuries  of  the  muscle  may  produce  wryneck  by 
leading  to  its  fibrous  degeneration.  In  other  cases  the 
wryneck  may  be  due  to  paralytic  changes  in  the  muscle 
of  the  opposite  side,  or  it  may  be  a  symptom  of  cervical 
caries ;  but  this  form  can  be  readily  recognised  by  the  fact 
that  the  chin  points  towards  the  affected  sterno-mastoid, 


222      THE    SURGICAL    DISEASES    OF    CHILDREN 

whilst  in  the  other  forms  it  points  away  from  the  muscle. 
The  contraction  of  the  trapezius,  of  the  splenius,  and  of 
other  muscles  of  the  back  of  the  neck  sometimes  produces 
various  modifications  of  wryneck.  The  prognosis  depends 
very  much  upon  the  cause. 

Treatment. — In  the  mildest  forms  of  wryneck,  some 
form  of  elastic  apparatus  is  alone  necessary,  and  Mr. 
Golding-Bird's  method  is  a  good  and  useful  one.  It 
consists  of  "  a  rubber  door-spring  attached  above  to  a 
webbing  head-band  laced  round  the  crown  of  the  head  and 
below  to  a  stout  hook  sewn  on  to  a  pair  of  stays,  tempor- 
arily worn  for  the  purpose.  The  rubber  spring  has 
lengths  of  tape  at  its  ends  whereby  it  is  fastened,  and 
by  means  of  which  the  tension  can  be  regulated."  The 
tension  apparatus  need  only  be  worn  during  the  day ;  and 
if  this  be  done  for  two  or  three  months,  a  cure  may  be 
effected. 

In  more  severe  cases,  however,  much  more  prolonged 
treatment  is  necessary.  When  the  contraction  of  the 
sterno-mastoid  is  slight,  and  the  wryneck  is  obviously 
due  to  it  alone,  division  of  its  lower  attachments  affords 
excellent  results,  if  care  be  taken  to  keep  the  head  erect 
during  the  process  of  repair.  The  muscle  is  divided 
either  by  the  open  method  or  subcutaneously  ;  personally 
I  prefer  to  perform  the  operation  subcutaneously.  The 
child  is  anaesthetised,  its  neck  is  exposed  upon  the 
affected  side,  and  the  two  origins  of  the  sterno-mastoid 
are  separately  divided  from  behind  forwards,  the  knife 
being  entered  upon  the  inner  side  in  each  case,  and  the 
cut  being  made  obliquely  downwards  towards  the  clavicle. 
The  division  of  the  muscle  is  very  often  followed  by  a 
rumpling  of  the  deep  fascia,  which  may  lead  an  inex- 
perienced operator  to  suppose  that  he  has  not  completely 
divided  the  muscle.      He  should  not,  however,  be  tempted 


WRYNECK 


223 


to  enter  his  tenotome  a  second  time,  though  many  sur- 
geons recommend  the  complete  division  of  the  deep  fascia 
in  all  cases  where  it  is  deemed  expedient  to  resort  to 
tenotomy  for  the  cure  of  wryneck.     Care  must  be  taken 


Fig.  23.— Lorenz's  head-swing  for  use  in  cases  of  wryneck. 
[From  Hoffa's  "  Lel\.rbv.ch."~\ 

to  ensure  asepsis,  and  the  two  punctures  are  closed  with 
cotton  wool  soaked  in  collodion. 

A  bandage  is  put  on,  and  the  head   is  at  once  placed 
straight,  or  it  is  pulled  a  little  over  to  the  opposite  side, 


224      THE    SURGICAL    DISEASES    OF    CHILDREN 

and  is  secured  in  that  position  by  means  of  a  plaster  case 
passing  round  the  thorax  and  across  the  head  at  the 
forehead.  This  is  left  in  position  for  eight  to  ten  days 
before  it  is  taken  off,  and  by  that  time  the  wound  will 
be  healed.  Some  fixed  support  capable  of  regulation  will 
be  required,  and  it  must  be  supplemented  by  the  use  of 
the  head-swing  (fig.  23),  shampooing,  and  gymnastics. 
The  cheapest  form  of  head  support  is  made  by  moulding 
two  collars  of  poroplastic  felt,  one  across  the  top  of  the 
shoulder  to  form  a  tippet,  and  a  second  over  it  round  the 
neck  in  such  a  manner  that  its  rounded  edge  takes  a 
purchase  beneath  the  jaw,  and  thus  supports  the  neck  in 
an  erect  position.  If  it  be  considered  desirable,  the  sup- 
port can  be  made  of  leather,  and  the  two  collars  may  be 
connected  together  by  a  special  spring  to  maintain  con- 
stant traction  in  the  required  direction.  This  forms  the 
essence  of  Weinberg's  apparatus,  but  I  do  not  find  that  it 
is  very  serviceable  in  effecting  the  purpose  for  which  it 
is  constructed. 


CHAPTER  X 

NON-TUBERCULOUS  FORMS  OF  ARTHRITIS 

TRAUMATIC  ARTHRITIS. 

Simple  traumatic  arthritis,  whether  due  to  injury  or  to 
perforating  wounds  of  the  joints,  presents  the  same  symp- 
toms, runs  the  same  course,  and  requires  the  same  treat- 
ment as  in  adults.  The  prognosis,  however,  is  rather 
better  in  children  than  in  adults,  and  when  suppuration 
occurs  there  should  be  no  hesitation  in  laying  the  joint 
freely  open  and  thoroughly  draining  it. 

HYDROPS  ARTICULI. 

Hydrops  articuli  of  a  very  chronic  form  sometimes  oc- 
curs in  the  knees  of  children  without  any  obvious  cause. 

etiology. — The  prolonged  swelling  sometimes  leads  to 
the  protrusion  of  hernise  of  the  synovial  membrane,  and  is 
sometimes  associated  with  dilatation  of  the  deeply  seated 
bursse.  I  believe  that  such  cases  are  generally  tubercu- 
lous in  origin  (p.  127),  though  in  other  cases  they  are 
perhaps  associated  with  that  group  of  symptoms  known  as 
osteo-arthritis  (p.  227),  for  this  disease  is  occasionally  met 
with  as  a  pathological  curiosity  about  puberty. 

Treatment. — The  fluid  may  be  removed  by  an  incision 
carried  along  the  side  of  the  joint  if  asepsis  can  be  en- 
sured, when  the  joint  shows  symptoms  of  weakness,  or  when 
there  are  other  pressure  symptoms  of  importance.  The 
wound  should  be  sutured  with  horsehair,  dressed  antisep- 

225  q 


2  26      THE    SURGICAL    DISEASES    OF    CHILDREN 

tically,  and  the  limb  should  afterwards  be  kept  at  rest  by 
the  application  of  a  plaster-of-Paris  splint  until  the  wound 
has  healed. 

SECONDARY  INFECTIVE  ARTHRITIS.18* 

etiology. — The  exanthemata  are  often  associated  with 
joint  trouble  in  children.  Scarlet  fever,  typhoid,  measles, 
mumps,  diphtheria,  and  smallpox  may  all  develop  symp- 
toms of  arthritis  in  their  course.  The  inflammation  may  be 
a  mere  neuralgia  of  the  joint,  or  it  may  be  a  true  synovitis, 
either  serous  throughout,  serous  becoming  suppurative,  or 
suppurative  from  the  beginning.  The  joints  of  the  lower 
extremity  are  more  often  affected  than  the  shoulder,  elbow, 
or  wrist.  Spontaneous  dislocation  may  occur  as  a  result 
of  the  inflammatory  conditions,  and  this  is  said  to  be  of 
especial  frequency  in  the  hip.  The  exact  time  of  the 
occurrence  of  the  dislocation  is  often  overlooked,  as  the 
deformity  is  masked  by  the  synovial  swelling.  Where 
dysentery  is  common,  similar  joint  affections  have  been 
observed  in  young  people. 

Treatment. — The  treatment  consists  in  keeping  the 
joint  at  rest  and  allaying  inflammation  by  the  ordinary 
measures.  The  joint  must  be  laid  open  and  drained  if  it 
suppurates  ;  means  must  be  taken  by  extension  to  prevent 
spontaneous  displacement  or  dislocation,  and  when  it  occurs, 
care  must  be  taken  not  to  overlook  it.  A  secondary  dis- 
location can  sometimes  be  reduced ;  but  if  this  is  impos- 
sible, attempts  may  be  made  either  to  form  a  new  joint 
by  employing  passive  movements,  or  means  may  be  taken 
to  ensure  firm  anchylosis  according  to  the  joint  which  is 
affected.  An  osteotomy  may  be  required  when  the  disloca- 
tion has  been  overlooked,  for  anchylosis  in  a  faulty  position 
often  results,  and  the  operation  is  usually  associated  with 


NON-TUBERCULOUS    FORMS    OF    ARTHRITIS    2  27 

a  tenotomy  to  enable  the  limb  to  be  brought  down  so  as  to 
lie  parallel  to  its  fellow. 

OSTEO-ARTHRITIS. 

A  secondary  infective  arthritis  occasionally  assumes  a 
chronic  form  in  children,  and  leads  to  a  condition  which 
is  known  for  the  present  as  osteo-arthritis.  It  is  seen  more 
often  after  scarlet  fever  than  after  the  other  exanthemata. 
Many  joints  are  affected,  and  the  child  is  quickly  crippled 
by  the  swelling  and  pain.  The  aetiology  and  pathology  of 
this  condition,  like  that  of  osteo-arthritis  itself,  require 
further  study. 

Prognosis. — The  prognosis  is  very  bad ;  such  children 
do  not  recover  when  the  symptoms  are  well  marked,  and, 
unfortunately  for  themselves  and  their  attendants,  do  not 
soon  die. 

Treatment. — The  treatment  can  only  consist  of  local 
applications  to  the  affected  joints  for  the  purpose  of  allay- 
ing the  pain. 

GONORRHEAL  ARTHRITIS.18  b 
Acute  inflammation  of  a  single  joint  is  occasionally  met 
with  in  infants  who  are  suffering  from  purulent  conjuncti- 
vitis, and  in  girls  who  are  brought  for  the  treatment  of  a 
purulent  vaginitis. 

Pathology. — These  inflammations  of  a  single  joint 
have  been  shown  to  occur  in  those  cases  in  which  the  pus 
from  the  vagina  and  the  conjunctiva  contained  Neisser's 
gonococcus. 

Symptoms.  —  Richardiere18b  and  Deutschmann  have 
each  recorded  cases  in  which  one  of  the  large  joints  be- 
came affected  with  an  acute  synovitis  a  fortnight  after  the 
appearance  of  a  purulent  discharge  containing  gonococci. 
The  course  and  symptoms  were  similar  in  every  respect  to 
those  occurring  in  the  gonorrhceal  arthritis  of  adults. 


2  28      THE    SURGICAL    DISEASES    OF    CHILDREN 

Treatment. — The  affected  limb  should  be  fixed  upon  a 
splint,  evaporating  lotions  should  be  applied  to  the  in- 
flamed joint,  and  the  source  of  infection  should  be  removed 
by  curing  the  purulent  discharge  as  quickly  as  possible. 

SYPHILITIC  ARTHRITIS. 

Surgeons  are  so  accustomed  to  see  tuberculous  inflam- 
mation in  joints,  that  they  are  apt  to  overlook  the  various 
arthritic  manifestations  of  syphilis. 

Varieties,  (a)  Commencing  in  the  epiphyseal  line. — 
Arthritis,  secondary  to  syphilitic  inflammation  of  the 
epiphyseal  line,  occasionally  takes  place,  and  it  must  be 
treated  on  the  same  lines  as  the  succeeding  form. 

(&)  Commencing  in  the  joint. — The  joints  in  infants  are 
sometimes  affected  by  a  syphilitic  inflammation  commenc- 
ing in  the  joint,  which  may  be  serous,  but  is  more  often 
purulent.  It  sometimes  attacks  only  a  single  large  joint, 
but  two  or  three  joints  are  generally  affected.  The  cap- 
sule of  the  joint  soon  yields,  and  extensive  diffuse  abscesses 
are  formed  which  may  open  spontaneously.  Good  evidence 
of  inherited  syphilis  is  usually  available  in  such  cases. 
The  treatment  consists  in  laying  the  joint  open,  draining 
it  freely,  and  giving  the  child  grey  powder.  Free  move- 
ment is  usually  obtained  in  the  joint  when  the  child 
survives  the  process  of  suppuration. 

(c)  Gummatous  Arthritis.  —  Syphilitic  arthritis  also 
occurs  in  later  childhood,  either  in  the  form  of  a  gumma- 
tous infiltration  of  the  bone  and  of  the  fibrous  tissue  out- 
side the  joint,  or  as  a  gummatous  synovitis.  The  disease 
in  either  case  is  extremely  likely  to  be  mistaken  for  tuber- 
culous arthritis ;  but  its  rather  more  chronic  course,  the 
slight  though  marked  evidence  of  syphilis  in  other  parts 
of  the  body,  and  the  smaller  amount  of  pain,  will  generally 
serve  to  distinguish  the  syphilitic  from  the  tuberculous 


NON-TUBERCULOUS    FORMS    OF    ARTHRITIS    229 

type  of  disease.  The  prognosis  is  good,  except  in  those 
cases  where  the  cartilages  of  several  joints  are  extensively 
involved;  for  in  these  cases  the  patients  die  from  the 
effects  of  the  syphilis  upon  the  nervous  or  digestive  sys- 
tems. The  following  case  illustrates  very  well  the  course 
run  by  a  case  of  gummatous  arthritis,  as  well  as  the  treat- 
ment to  be  adopted  for  its  cure : — 

A  boy,  aged  14,  came  under  my  care  at  the  Victoria 
Hospital  for  Children  on  the  last  day  of  January,  1894,  to 
be  treated  for  an  inflammation  of  the  right  knee.  He  had 
diphtheria  in  September,  1893,  and  about  a  month  after- 
wards sores  appeared  upon  his  body.  He  was  noticed  to 
be  walking  lamely  about  the  end  of  December.  His 
younger  brother  has  had  one  ankle-joint  excised,  presum- 
ably for  tuberculous  arthritis.  The  patient's  complexion 
on  admission  was  muddy,  and  scattered  over  his  trunk, 
limbs,  and  scalp  were  patches  of  superficial  ulceration 
covered  with  thick  scales  or  with  black  and  raised  crusts. 
The  voice  was  husky,  but  his  teeth  were  healthy,  and 
there  was  no  evidence  of  keratitis,  or  of  iritis,  either 
present  or  remote.  The  glandulae  concatenate  on  both 
sides  of  the  neck  were  slightly  enlarged.  The  right 
knee  was  affected  with  synovitis.  It  measured  12^- 
inches  over  the  centre  of  the  patella,  whilst  the  left  one 
only  measured  10|  inches  in  circumference  at  the  same 
level.  There  was  a  little  synovial  fluid  in  the  left  knee. 
The  synovial  membrane  in  both  joints  appeared  to  be 
thickened,  and  this  was  especially  marked  at  the  sides. 
The  patient  occasionally  had  a  little  throbbing  pain  at 
nights,  but  unless  the  knee  was  moved  he  did  not  com- 
plain of  pain,  and  he  had  never  felt  any  starting  pains  at 
night. 

The  boy  was  brought  by  his  mother,  who  presented  such 
obvious  signs  of  tertiary  syphilis  that  he  was  at  once  ordered 


230      THE    SURGICAL    DISEASES    OF    CHILDREN 

one-grain  doses  of  grey  powder,  and  in  ten  days'  time  his 
complexion  had  cleared  and  his  voice  was  less  husky. 
There  was  also  less  synovial  effusion  in  the  right  knee, 
whilst  the  left  appeared  to  be  healthy.  This  improvement 
continued  until  March  7th,  when  the  patient  was  allowed 
to  go  home  with  his  right  knee  in  a  plaster-of -Paris  case. 
He  returned  on  March  26th,  complaining  of  much  pain  in 
both  knees,  with  increased  swelling.  A  plaster-of-Paris 
splint  was  again  put  upon  each  leg.  He  returned  again 
on  April  2nd,  with  increased  swelling  of  both  knees  and 
some  synovitis  of  both  elbows,  and  he  then  confessed  that 
he  had  not  taken  any  powders  for  a  fortnight.  He  was 
made  to  understand  that  medicine  was  necessary,  and  was 
ordered  to  continue  the  one-grain  doses  of  grey  powder 
three  times  a  day.  His  elbows  were  less  troublesome  on 
April  9th,  though  his  knees  were  still  swollen.  He  was 
therefore  given  half -drachm  doses  of  perchloride  of  mercury 
with  five  grains  of  potassium  iodide  three  times  a  day,  and 
a  week  later  he  reappeared,  saying  that  his  elbows  were 
well,  his  knees  better,  and  that  he  had  not  suffered  any 
pain  since  he  had  been  taking  the  new  medicine.  He  in- 
creased in  weight  from  64^  lbs.  to  71|  lbs.  between  April 
16th  and  April  30th,  and  has  remained  well  and  at  work 
as  an  errand  boy  ever  since. 

Mr.  Clutton  first  drew  attention  to  these  interesting 
cases ;  and  though  they  are  often  associated  with  intersti- 
tial keratitis,  this  is  not  always  the  case,  as  is  shown  by 
the  above  instance,  where  the  stress  of  the  disease  fell 
upon  the  skin  and  synovial  membranes,  and  not  upon  the 
cornea  and  teeth. 

(d)  Chondro- Arthritis. — The  worst  form  of  syphilitic 
arthritis  is  fortunately  the  rarest,  for  it  does  not  respond 
to  the  ordinary  antisyphilitic  remedies,  and  it  is  practi- 
cally   incurable.     It   is   that   form  of   inherited   syphilis 


NON-TUBERCULOUS    FORMS    OF    ARTHRITIS    23  [ 

which  is  seen  as  one  of  the  later  manifestations  about 
puberty.  The  bones  and  joints  are  extensively  affected 
by  a  rarefying  osteitis,  with  a  deposit  of  caseating  material 
in  the  cancellous  tissue.  A  similar  process  takes  place 
in  the  articular  cartilages,  and  leads  to  the  formation  of 
irregular  grooves  and  pits. 

Symptoms. — The  condition  may  be  preceded  by  tran- 
sient attacks  of  synovitis,  with  evidence  of  chronic  inflam- 
mation of  the  long  bones.  There  are  usually  many  other 
manifestations  of  syphilis,  with  evidence  of  marked  intra- 
ocular lesions. 

Diagnosis. — These  cases  are  very  likely  to  be  mistaken 
for  cases  of  tuberculous  disease  of  the  bones  and  joints. 
They  are  to  be  distinguished,  however,  by  their  slower 
progress,  by  their  slighter  tendency  to  fungation,  and  by 
their  association  with  other  unmistakable  signs  of  in- 
herited syphilis. 

Treatment. — These  patients  are  often  so  completely 
permeated  by  syphilis  that  very  little  can  be  done  for 
them.  Mercurial  vapour-baths,  perhaps,  afford  them  the 
best  chance  of  recovery,  with  the  inunction  of  10  per  cent, 
oleate  of  mercury  at  the  affected  joints. 

HEMORRHAGIC  DISEASE. 

Two  definite  forms  of  haemorrhagic  disease  occur  in  chil- 
dren— the  one  peculiar  to  the  individual,  the  other  charac- 
teristic of  the  family  to  which  he  belongs. 

(1)  Passive  heemorrharjes  are  of  no  very  unusual  occur- 
rence in  newly-born  children  ;  but  it  is  only  recently  that 
they  have  been  scientifically  studied  by  French  and 
American  surgeons.  Dr.  Townsend,  of  Boston,  has  collected 
a  series  of  cases  which  show  that  such  haemorrhages  are 
most  frequent  from  the  stomach,  navel,  intestines,  vaginrt, 
mouth,  and  nose.     They  also  occur  as  bruises  beneath  the 


232      THE    SURGICAL    DISEASES    OF    CHILDREN 

skin.  They  are  usually  seen  within  the  first  seven  days 
of  birth,  the  majority  beginning  on  the  second  or  third 
day. 

Prognosis. — The  affection  is  a  serious  one.  Half  the 
cases  which  die  are  fatal  within  the  first  day,  and  the 
remainder  within  a  week.  Recovery  takes  place  in  the 
slighter  and  more  favourable  cases  within  nine  days. 
The  haemorrhage  is  associated  with  a  marked  rise  of  tem- 
perature. Its  cause  is  at  present  unknown,  but  it  is  not 
associated  with  any  injury  to  the  child,  and  it  is  quite 
unconnected  with  haemophilia. 

Treatment. — Rest,  careful  feeding,  warmth,  and  minute 
doses  of  alcoholic  stimulants  during  the  stage  of  collapse 
seem  to  give  the  best  results. 

(2)  Haemophilia  differs  from  the  previous  condition  in 
the  fact  that  it  is  rarely  seen  before  the  end  of  the  first 
year,  that  it  occurs  in  families,  and  that  in  them  it  is  more 
frequent  amongst  the  males  than  the  females ;  whilst 
during  the  haemorrhage  there  is  a  local,  and  not  a  consti- 
tutional, rise  of  temperature.  Members  of  bleeding  fami- 
lies are  always  subjects  of  great  anxiety  to  the  surgeon  in 
whose  neighbourhood  they  happen  to  live  ;  and,  in  spite  of 
all  treatment,  they  usually  continue  to  bleed  until  they 
either  die  or  Nature  herself  arrests  the  haemorrhage. 


*&"■ 


HEMOPHILIC  ARTHRITIS.19 

Symptoms. — Sudden  swellings  of  the  ankles,  knees, 
and  elbows  often  take  place  in  children  who  are  known  to 
be  "  bleeders, ':  or  to  come  of  a  haemorrhagic  stock.  A  few 
years  ago  I  had  two  brothers  who  came  to  me  from  time  to 
time  on  account  of  painful  swellings  of  their  knees  and 
ankles.  The  attacks  came  on  spontaneously ;  the  skin 
over  the  affected  joints  was  glazed,  shiny,  and  hotter  than 


NON-TUBERCULOUS    FORMS    OF    ARTHRITIS    233 

that  covering  the  unaffected  parts.  There  was  a  good  deal 
of  local  tenderness,  and  there  was  sometimes  ecchymosis. 
Movement  in  the  ankles  was  impaired,  but  the  knees  were 
free. 

Pathology. — The  joints  in  such  cases  are  remarkably 
injured,  owing,  as  some  suppose,  to  the  fact  that  the  blood 
effused  into  them  maintains  its  vitality  for  a  long  period 
of  time,  though  this  case  is  inadequate  to  explain  the 
results.  The  cartilages  become  shaggy,  and  the  ends  of 
the  bones  are  lipped  and  irregular  in  the  manner  once 
thought  to  be  characteristic  of  osteo-arthritis,  but  which 
now  appears  to  be  common  to  all  forms  of  very  chronic 
joint  irritation.  A  greater  or  less  amount  of  anchylosis 
with  deformity  is  a  frequent  result  of  these  changes.  The 
bleeding  comes  from  the  capillaries  rather  than  from  the 
large  arteries,  so  that  some  surgeons  hold  that  operations 
of  urgency  are  not  contra-indicated  in  haemophilia. 

Treatment. — The  surgeon  in  all  cases  where  haemo- 
philia is  present  should  warn  the  child's  parents  that  it 
is  their  duty  to  tell  the  patient  the  nature  of  his  disease 
as  soon  as  he  is  of  an  age  to  understand,  for  many  dangers 
may  thereby  be  avoided.  No  styptics  should  be  used  to  the 
bleeding  point,  as  they  are  always  useless.  Prof.  A.  E. 
Wright 19  states  that  the  coagulation  time  of  the  blood  can 
be  shortened  in  cases  of  haemophilia  by  the  administration 
of  three  to  five-grain  doses  of  calcium  chloride  three  times 
a  day ;  and  this  general  treatment  may  be  supplemented 
by  allowing  the  patient  to  inhale  carbonic  acid  gas  mixed 
with  atmospheric  air.  The  local  treatment  consists  in 
casing  the  affected  joint  in  a  well-moulded  splint  of  pla'ster- 
of-Paris,  which  can  be  easily  removed.  The  splint  should 
be  applied  until  the  heat  and  swelling  have  subsided,  but 
as  soon  as  possible  gentle  passive  movement  and  shampoo- 
ing  should   be  adopted.      The  result  of   repeated  passive 


234      THE    SURGICAL    DISEASES    OF    CHILDREN 

haemorrhages  into  the  joints  is  so  bad  that  Prof.  Konig 
has  recently  advocated  the  puncture  and  subsequent  wash- 
ing out  of  such  joints  with  a  1  in  60  solution  of  carbolic 
acid — a  method  of  treatment  which  I  should  be  very  loth 
to  adopt. 


CHAPTER  XI 

ACQUIRED    DISLOCATIONS    AND    CONGENI- 
TAL  DISPLACEMENTS  IN   JOINTS 

Dislocations  from  injury  are  unusual  in  children,  partly 
on  account  of  the  elasticity  of  the  capsules  and  ligaments 
of  their  joints,  and  partly  owing  to  the  want  of  rigidity 
possessed  by  the  various  elements  entering  into  the  con- 
struction of  their  skeletons.  Secondary  dislocations  as  a 
result  of  disease  are  also  uncommon,  though  partial  dis- 
placements are  by  no  means  rare.  Congenital  dislocations 
are  occasionally  met  with. 

DISLOCATION   OF   THE  SEPTUM  NASI. 

Mr.  Walsham  says  that  dislocation  of  the  anterior  end 
of  the  septum  nasi  from  the  nasal  spine  is  an  exceedingly 
common  result  of  injury. 

Symptoms. — It  gives  rise  to  an  unsightly  red  promi- 
nence just  within  the  nostril,  and  usually  causes  the  tip  of 
the  nose  to  turn  slightly  to  the  opposite  side.  It  may  lead 
to  considerable  obstruction. 

Treatment. — The  most  satisfactory  method  of  treat- 
ment, he  says,  is  to  shave  away  the  superimposed  mucous 
membrane  and  the  underlying  cartilage,  layer  by  layer, 
till  the  patency  of  the  nostril  and  the  symmetry  of  the 
part  is  restored. 

235 


236      THE    SURGICAL    DISEASES    OF    CHILDREN 

LOWER  JAW. 

Dislocations  of  the  lower  jaw  are  practically  unknown 
in  children,  and  they  do  not  occur  with  great  frequency 
in  young  adults. 

Subluxation  of  the  jaw  has  been  known  since  the  time 
of  Sir  Astley  Cooper.  It  usually  occurs  in  young  people, 
and  is  very  prone  to  recur.  It  appears  to  be  due  to  relaxa- 
tion of  the  capsule,  ligaments,  and  muscles,  but  its  exact 
pathology  is  unknown.  The  exciting  causes  appear  to  be 
yawning  or  biting  upon  some  hard  substance.  Dr.  Hamil- 
ton describes  the  symptoms  in  his  own  case  as  being  a 
sudden  arrest  of  the  motions  of  the  jaw  with  the  mouth 
about  half  open,  the  arrest  of  motion  being  accompanied, 
or  more  usually  preceded,  by  a  sensation  of  slipping  in  one 
of  the  articulations.  The  chin  is  slightly  inclined  to  the 
opposite  side.  The  condyle  may  be  felt  somewhat  advanced 
in  its  socket,  and  while  it  remains  in  this  position  the 
patient  experiences  some  pain.  The  locking  in  his  case  was 
sometimes  upon  the  right  and  sometimes  upon  the  left  side. 

Treatment. — The  condyle  can  generally  be  made  to  fall 
into  place  by  a  voluntary  lateral  movement  of  the  jaw,  but 
occasionally  it  is  necessary  to  press  gently  against  the 
chin  with  the  hand. 

Prognosis. — The  annoyance  may  cease  as  the  patient 
becomes  older  and  stronger. 

ANCHYLOSIS   OF  THE  JAWS.ao 

etiology  and  Varieties. — Anchylosis  of  the  jaw  is 
by  no  means  infrequent  in  children.  It  is  bony  or  fibrous, 
bilateral  nearly  as  often  as  unilateral.  Its  movements  are 
sometimes  impeded  as  a  result  of  cicatrices  of  the  cheek, 
due  to  burns  and  various  ulcerative  processes.  True  bony 
anchylosis  occurs  after  injury  to  the  condyles,  as  a  result 


DISLOCATIONS  237 

of  suppuration  involving  the  glenoid  cavity  after  measles, 
scarlet  fever,  or  other  infective  disease,  or  from  the  open- 
ing of  a  cervical  or  retropharyngeal  abscess  into  the  joint. 
A  curious  spasmodic  form  is  sometimes  associated  with 
dental  caries,  or  from  the  irritation  of  retained  wisdom 
teeth. 

Treatment. — The  symptoms  are  obvious,  for  there  is 
difficulty,  or  even  absolute  inability,  to  open  the  jaws,  and 
any  attempt  at  mastication  may  be  accompanied  by  severe 
pain. 

The  treatment  is  most  unsatisfactory.  The  employment 
of  wedges  and  the  forcible  opening  of  the  mouth  by  gags 
are  cruel  and  futile  expedients,  and  should  not  be  adopted 
except  in  the  very  simplest  cases  of  fibrous  anchylosis. 
A  plastic  operation  after  division  of  the  bands  of  scar 
tissue  affords  some  measure  of  relief  when  the  impaired 
movement  is  due  to  cicatrices. 

Operative  measures  are  alone  beneficial  in  cases  of  bony 
anchylosis.  Many  forms  of  operation  have  been  devised, 
each  with  the  design  of  obtaining  a  false  joint  either  on 
one  or  both  sides  of  the  jaw,  as  the  occasion  requires.  The 
methods  of  Swain,  Esmarch,  Mears,  and  Bottini  are  said 
to  yield  the  most  satisfactory  results.  Mr.  Swain  advises 
that  an  incision  about  an  inch  and  a  half  in  length  be 
made  at  the  angle  of  the  jaw,  parallel  with  it,  and  taking 
the  angle  as  the  centre  of  the  incision.  The  knife  is  car- 
ried down  to  the  bone,  the  soft  parts  are  retracted,  and 
the  periosteum,  carrying  with  it  the  attachments  of  the 
masseter  and  the  internal  pterygoid  muscles,  is  raised 
from  the  outer  and  inner  surfaces  of  the  angle.  A  narrow 
saw  is  then  applied,  and  a  wedge-shaped  piece  of  bone  is 
removed.  This  piece  of  bone  should  include  the  angle  of 
the  jaw,  and  the  base  of  the  wedge  should  measure  about 
an  inch.     A  similar  operation  may  be  at  once  performed 


238      THE    SURGICAL    DISEASES    OF    CHILDREN 

upon  the  opposite  side  if  the  anchylosis  is  bilateral.  The 
operation  is  not  a  difficult  one  ;  there  is  no  bleeding,  no 
important  structures  are  likely  to  be  injured  if  it  is  per- 
formed subperiosteally,  good  movement  is  obtained,  and 
the  scar  is  not  very  perceptible.  It  is  important  that 
union  by  first  intention  should  be  obtained  in  these  cases  ; 
for  if  suppuration  takes  place,  it  is  very  likely  that  bony 
union  will  take  place. 

Passive  movement  is  begun  upon  the  third  day,  and  is 
repeated  daily  for  a  period  of  six  to  eight  weeks.  Dr. 
Mears  suggests  that  the  use  of  American  chewing-gum  is 
serviceable  in  these  cases  to  maintain  the  movements  of 
the  jaw  during  the  formation  of  the  false  joint.  It  is 
often  difficult  to  decide  which  is  the  anchylosed  side  in 
cases  of  firm  bony  union ;  but  in  cases  of  doubt  there  is  a 
slight  springing  of  the  jaw,  which  is  more  noticeable  upon 
the  unaffected  side  ;  it  is  best  marked  during  mastication. 
The  jaw  in  most  cases  is  slightly  displaced  towards  the 
affected  side,  owing  to  the  absorption  of  bone  and  carti- 
lage, which  occurs  during  the  process  of  anchylosis.  This 
displacement  is  easily  detected  by  noticing  the  intervals 
between  the  incisors  in  the  upper  and  lower  jaws. 

SHOULDER. 

Primary  dislocations  of  the  shoulder  are  very  infre- 
quent in  children,  and  their  place  is  taken  by  separation 
of  the  upper  epiphysis  of  the  humerus  ;  but  dislocations 
at  the  elbow  and  of  the  fingers  are  by  no  means  rare. 
The  signs  and  symptoms  of  separated  epiphysis  have 
already  been  given  (p.  171). 

ELBOW. 
Dislocation  of  the  elbow  in  children  is  generally  due  to 
falls  upon  the  hand  with  the  palm  downwards.    The  radius 


DISLOCATIONS  239 

and  ulna  are  usually  displaced  backwards,  probably  owing 
to  the  want  of  development  of  the  coronoid  process  of  the 
ulna  ;  though  the  radius  may  be  dislocated  alone,  its  head 
being  driven  forwards. 


o 


DISLOCATIONS  OF  RADIUS  AND  ULNA 
BACKWARDS. 

Symptoms. — The  symptoms  presented  by  a  double  dislo- 
cation of  both  bones  backwards  are  that  the  elbow  is  slightly 
bent,  and  is  so  fixed  that  it  can  be  moved  somewhat  more 
readily  from  side  to  side  than  in  the  ordinary  direction  ;  the 
hand  and  arm  are  moderately  pronated ;  the  lower  end  of 
the  humerus  projects  forward,  whilst  the  upper  ends  of  the 
radius  and  idna  can  be  felt  posteriorly. 

It  is  important  to  know  the  relative  positions  of  the 
olecranon  and  condyles  in  a  normal  elbow,  as  in  no  other 
way  can  a  correct  diagnosis  be  made  of  obscure  injuries 
in  this  region.  Holden,  in  his  Landmarks,  says  that 
when  the  elbow  is  extended  the  highest  part  of  the  ole- 
cranon is  never  above  a  line  joining  the  most  prominent 
part  of  the  external  and  internal  condyles  posteriorly,  but 
it  always  lies  in  this  line.  With  the  elbow  at  right  angles, 
the  point  of  the  olecranon  is  vertically  below  the  line  of 
the  condyles.  In  extreme  flexion,  the  point  of  the  ole- 
cranon lies  in  front  of  the  line  of  the  condyles.  In  cases  of 
backward  dislocation  the  olecranon  lies  at  a  higher  level 
than  the  internal  condyle ;  but  the  distance  between  the 
acromion  and  the  external  condyle  of  the  humerus  is  iden- 
tical upon  the  two  sides.  An  intelligent  child  will  some- 
times complain  of  a  referred  pain  felt  along  the  inner  side 
of  its  hand,  owing  to  the  stretching  of  the  ulnar  nerve 
over  the  projecting  bone,  and  there  may  be  numbness 
along  the  course  of  the  median  nerve. 

Diagnosis. — A  diagnosis   has   to   be   made   between  a 


24O      THE    SURGICAL    DISEASES    OF    CHILDREN 

backward  dislocation  of  a  radius  and  ulna  and  fractures  at 
or  near  the  lower  epiphysis  of  the  humerus.  This  is  often 
very  difficult,  unless  the  patient  is  seen  directly  after  the 
injury,  for  swelling  soon  obliterates  all  the  landmarks  of 
the  elbow.  Flexion  of  the  arm  in  a  case  of  dislocation 
causes  the  olecranon  to  become  more  prominent,  whilst  in 
extension  the  prominence  is  diminished :  the  exact  con- 
trary of  this  is  observed  in  cases  of  fracture  at  the  base  of 
the  condyles. 

Treatment. — Reduction  can  generally  be  effected  with- 
out using  much  force,  either,  according  to  Sir  Astley  Cooper's 
method,  by  bending  the  elbow  round  the  knee,  so  that  the 
radius  and  ulna  are  pressed  backwards  until  they  are  dis- 
entangled from  the  humerus,  or  by  over-extending  and  then 
suddenly  flexing  the  arm.  The  proof  of  complete  reduction 
is  the  ability  to  flex  the  arm  to  a  right  angle.  The  sur- 
geon should  not  be  satisfied  until  his  patient  can  do  this  ; 
for,  in  a  case  of  separated  epiphysis,  the  deformity  will 
reappear  as  soon  as  traction  is  taken  off  the  arm ;  and  in 
cases  of  dislocation  it  sometimes  happens  that  only  one  of 
the  two  bones  is  replaced  in  its  normal  position,  unless  the 
surgeon  pays  attention  to  the  voluntary  power  possessed 
by  the  joint  when  he  thinks  reduction  has  been  effected. 

The  arm  must  afterwards  be  put  upon  a  well-padded 
rectangular  splint,  and  it  should  be  slung  with  the  points 
of  the  fingers  directed  upwards.  The  elbow  should  be 
covered  with  an  evaporating  lotion,  and  the  splint  should 
be  removed  at  the  end  of  a  week  or  ten  days,  massage  and 
gentle  passive  movements  being  then  adopted. 

Prognosis. — The  result  is  usually  good,  but  anchylosis 
occurs  rather  more  often  after  dislocations  of  the  elbow 
than  in  other  joints.  Arthrotomy  or  excision  of  the  joint 
must  be  performed  in  these  unfortunate  cases  if  other 
means  fail. 


DISLOCATIONS  24 1 

DISLOCATION  OF  RADIUS  AND  ULNA 
FORWARDS. 

Dislocation  of  the  radius  and  ulna  forwards  is  sometimes 
seen  in  children,  but  less  frequently  than  the  preceding 
form.  It  is  said  to  be  caused  by  a  fall  upon  the  elbow  with 
the  arm  in  a  position  of  forced  flexion.  It  is  rather  more 
frequent  in  children  than  in  adults,  and  it  is  often  associ- 
ated with  detachment  of  the  internal  epicondyle. 

Symptoms. — The  forearm  is  shortened  and  flexed  upon 
the  arm  when  the  dislocation  is  complete,  but  the  forearm 
is  extended  in  the  incomplete  forms. 

Treatment. — Reduction  is  effected  in  the  incomplete 
forms  by  extension,  and  in  the  complete  form  by  flexion 
first  and  extension  afterwards,  the  arm  being  treated  in 
the  same  way  as  after  dislocation  of  both  bones  backwards. 

DISLOCATION  OF  THE  RADIUS. 

Dislocation  of  the  radius  forwards  is  usually  associated 
with  rupture  of  the  orbicular  ligament.  It  may  be  pro- 
duced by  falls  upon  the  elbow  or  upon  the  hand  with  the 
arm  extended  and  pronated,  or  by  a  direct  blow  upon  the 
posterior  surface.  The  head  of  the  bone  can  be  felt  in  its 
new  position,  and  the  tendon  of  the  biceps  is  relaxed,  whilst 
the  forearm  is  more  or  less  pronated.  Flexion  beyond  a 
right  angle  is  impossible,  as  the  radius  strikes  against  the 
front  of  the  humerus.  The  contraction  of  the  biceps  is  the 
chief  obstacle  to  reduction  after  the  injury,  and  it  tends  to 
reproduce  the  displacement  when  the  head  of  the  radius 
has  been  put  back  into  its  normal  position. 

Treatment. — Reduction  is  effected  by  first  flexing  the 
elbow,  and  then  causing  an  assistant  to  extend  the  arm 
whilst  the  surgeon  presses  the  head  of  the  bone  into  posi- 
tion.    The  necessary  manipulation  is  generally  attended 

R 


242      THE    SURGICAL    DISEASES    OF    CHILDREN 

with  success,  but  the  tendency  to  dislocation  is  so  great 
that  the  elbow  must  be  kept  bent  for  at  least  three  weeks. 

SUBLUXATION  OF  THE  HEAD  OF  THE  RADIUS. 

A  remarkable  accident  sometimes  occurs  in  children 
which  is  provisionally  described  as  a  subluxation  of  the 
head  of  the  radius.  It  was  known  to  Hippocrates  and  to 
Celsus,  and  was  described  by  Fournier  in  1671.  Attention 
has  recently  been  called  to  it  by  Mr.  Jonathan  Hutchinson, 
jun.,  and  by  Mr.  Mansell  Moullin  in  England,  and  by  Dr. 
van  Arsdale  and  Dr.  van  Santvoord  in  New  York  (p.  180). 

^Etiology. — The  injury  always  results  from  some 
cause  which  leads  a  child  suddenly  to  bear  its  entire 
weight  upon  the  arms  whilst  they  are  fully  extended.  It 
occurs  in  children  under  nine  years  of  age,  but  it  is  most 
common  under  six.  I  have  seen  the  accident  result  from 
a  fit  of  temper  when  an  obstinate  nurse  has  jyulled  in  one 
direction  and  a  still  more  obstinate  child  has  pulled  in 
the  other. 

Symptoms. — The  child  immediately  allows  the  hand 
to  hang  downwards,  as  if  it  were  paralysed.  He  complains 
of  pain  in  the  wrist,  and  feels  pain  on  attempting  to  lift, 
bend,  or  extend  the  forearm.  There  is  no  marked  defor- 
mity of  the  arm  or  at  the  elbow,  but  the  arm  is  pronated 
and  slightly  flexed.  Pressure  over  the  head  of  the  radius 
always  causes  pain,  and  voluntary  supination  is  impossible. 

Morbid  Anatomy.  —  The  cause  of  the  condition  is 
quite  unknown,  although  many  theories  have  been  put 
forward  to  account  for  it.  It  is  perhaps  associated  with  a 
more  or  less  complete  displacement  of  the  small  and  ill- 
developed  head  of  the  radius  beneath  the  orbicular 
ligament. 

Diagnosis. — The  symptoms  are  so  characteristic  that, 


DISLOCATIONS  243 

coupled  with  a  history  of  the  injury,  they  are  not  likely  to 
be  mistaken  for  either  a  bruise  or  a  sprain  of  the  wrist  or 
elbow. 

Prognosis. — The  prognosis  is  good,  for  even  if  left  un- 
treated a  perfectly  useful  arm  results. 

Treatment. —  Extend  the  arm  by  pulling  upon  the 
hand,  supinate  it,  and  at  the  same  time  press  downwards 
and  backwards  upon  the  head  of  the  radius  until  it  has 
descended  to  a  level  with  the  articulating  surface  of  the 
humerus.  The  forearm  is  then  flexed  upon  the  arm,  so 
that  the  hand  passes  outside  the  shoulder,  the  pressure 
upon  the  head  of  the  radius  being  at  the  same  time 
vigorously  maintained.  The  arm  should  then  be  bandaged 
to  a  well-padded  rectangular  splint  for  three  or  four  days. 
The  supination  appears  to  be  the  most  important  part  of 
the  manipulation,  and  the  reduction  of  the  injury  is  usually 
effected  with  a  distinct  snapping  sound  and  sensation  at 
the  head  of  the  radius. 

DISLOCATION   OF  THE  PHALANGES.21 

Dislocations  of  the  phalanges  upon  each  other  or  at  the 
metacarpophalangeal  joint  occur  rather  frequently  in  chil- 
dren, either  from  falls  or  direct  injuries.  They  are  simple 
and  incomplete,  when  the  phalanx  has  not  left  the  head 
of  the  metacarpal,  or  they  are  simple  and  complete,  the 
phalanx  being  displaced  backwards.  Complex  forms  of 
backward  dislocation  also  occur  in  which  the  phalanx  of 
the  thumb  is  dislocated  backwards,  but  the  glenoid  liga- 
ment with  its  sesamoid  bone  becomes  turned  upon  itself, 
and  is  interposed  between  the  articular  surfaces  of  the 
metacarpal  and  the  phalanx  in  such  a  manner  as  to  render 
the  dislocation  irreducible.  I  am  indebted  to  Mr.  Battle 
for  his  kindness  in  lending  me  the  figures  24  and  25  which 
show  the  normal  and  injured  condition  of  structures  at  the 


244      THE    SURGICAL    DISEASES    OF    CHILDREN 

metacarpophalangeal  joint.  Faraboeuf  thinks  that  this 
accident  is  nearly  always  the  result  of  ill-judged  attempts 
to  reduce  the  simple  complete  form. 

Treatment. — Mr.  Battle,21  who  has  paid  much  attention 
to  these  injuries,  recommends  that  the  displaced  phalanx 
should  be  hyperextended  and  tilted  up  until  its  articular 


Fig.  21. 


Fig.  25. 


Diagrams  of  the  anatomical  structures  at  a  metacarpophalangeal  articula- 
tion, before  and  after  dislocation  of  the  joint. 

[From  blocks  kindly  lent  by  MV.  W.  H.  Battle.] 

Fig.  24. — Section  through  metacarpophalangeal  joint  (after  Henle).  M,  head 
of  the  metacarpal  bone ;  P,  base  of  the  first  phalanx  ;  a,  tendon  of  the  flexor 
profundus  digitorum ;  b,  tendon  of  the  flexor  sublimis  digitorum;  c,  glenoid 
ligament;  d,  dorsal  ligament  (absent,  according  to  Gray);  e,  vaginal  ligament ; 
/,  interosseous  ligament;  g,  tendon  of  extensor  communis  digitorum. 

Fig.  25. — Diagram  to  illustrate  the  position  of  the  glenoid  ligament,  antero- 
posterior section.  M,  metacarpal  bone ;  P,  phalanx  ;  c,  glenoid  ligament  dis- 
placed and  turned  upon  itself;  d,  ruptured  dorsal  ligament,  occasionally  present. 

surface  projects  anteriorly  under  the  skin.  The  two  fore- 
fingers should  then  be  placed  so  as  to  keep  it  in  position, 
and  pressure  should  at  the  same  time  be  made  against  the 
distal  extremity  of  the  metacarpal  bone.  Firm  pressure 
of  the  surgeon's  thumb  against  the  base  of  the  dislocated 
phalanx  will  then  permit  it  to  be  pushed  into  place.  The 
reduction  is  generally  easy,  and  is  accompanied  by  an 
audible  click.     In  complex  cases  the  base  of  the  phalanx 


DISLOCATIONS  245 

should  be  carried  backwards  along  the  dorsal  surface  of 
the  metacarpal  bone,  whilst  traction  is  made  upon  the 
thumb  so  as  to  pull  .the  ligament  with  its  sesamoid  bone 
more  fully  in  front  of  the  anterior  margin  of  the  articular 
surface  of  the  phalanx  before  flexion. 

An  anaesthetic  must  be  given  if  this  method  fails,  and 
the  glenoid  ligament  must  be  divided  subcutaneously.  The 
tenotome  is  entered  in  the  middle  line  and  on  the  dorsum 
of  the  metacarpal,  so  as  to  avoid  the  sesamoid  bone.  If 
reposition  cannot  yet  be  effected,  a  lateral  incision  should 
be  made  along  the  joint,  and  the  ligament  or  flexor  tendon 
must  then  be  replaced. 

After  severe  compound  fractures,  or  when  anchylosis  of 
a  joint  has  taken  place  as  a  result  of  an  injury,  the  head 
of  the  metacarpal  bone  may  be  excised,  passive  movement 
being  adopted  at  the  earliest  possible  opportunity. 

DISLOCATION   OF  THE  HIP. 

Traumatic  dislocations  of  the  hip  are  not  of  frequent 
occurrence  in  children.  I  have  only  seen  one.  The  head 
of  the  bone  lay  on  the  dorsum  ilii  in  a  boy  of  eight  years, 
and  it  was  reduced  without  difficulty  by  manipula- 
tion. Hamilton  records  several  instances  in  children  from 
six  months  old  and  upwards.  The  mechanism  of  produc- 
tion, the  varieties,  the  method  of  reduction,  and  the  after- 
treatment  are  the  same  as  in  adults. 

DISPLACEMENTS  IN  JOINTS  SECONDARY  TO 

DISEASE. 22 

Secondary  displacements  of  the  hip,  shoulder,  elbow,  and 
knee  are  of  frequent  occurrence  as  a  result  of  chronic  or 
destructive  inflammation  of  the  joints,  and  in  exceptional 
cases  true  dislocation  may  occur.  One  of  the  great  objects 
in  the  surgical  treatment  of  chronic  arthritis  is  to  prevent 


246      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  occurrence  of  such  accidents,  or  if  displacement  is 
inevitable,  to  minimise  its  evil  results.  Displacements  of 
the  shoulder  and  knee  are  often  coexistent  with  paralysis  of 
the  limbs.  They  are  caused  by  alterations  in  the  muscles, 
ligaments,  and  capsule,  owing  to  trophic  changes,  or  they 
may  be  produced  by  alterations  in  the  ends  of  the  bones 
themselves. 

Treatment.— Arthrodesis  (p.  195)  may  sometimes  be 
satisfactorily  performed  for  the  relief  of  this  condition  ; 
but  more  usually  some  form  of  orthopsedic  apparatus  is 
employed  to  render  the  limb  less  cumbersome. 

CONGENITAL  DISPLACEMENTS  IN  JOINTS. 

Congenital  displacements  have  been  described  in  the  lower 
jaw,  the  ensiform  cartilage  of  the  sternum,  at  either  end  of 
the  clavicle,  at  the  upper  end  of  the  humerus,  either  back- 
wards or  forwards  at  the  wrist,  at  the  fingers,  and  at  the 
patella.  The  details  of  these  congenital  defects  will  be 
found  in  the  works  of  R.  Smith  of  Dublin,  and  of  Jules 
Ouerin  of  Paris.  Such  displacements  are  rare ;  they  are 
treated  by  the  use  of  suitable  orthopaedic  apparatus,  and 
they  may  be  dismissed  without  further  remark.  Con- 
genital displacement  of  the  hip  and  knee  stand  on  rather 
a  different  footing.  Our  knowledge  of  their  pathology, 
causation,  and  treatment  has  been  lately  advanced,  and 
they  may  therefore  be  considered  in  greater  detail. 

Congenital  Displacement  of  the  Hip.23 

Morbid  Anatomy— There  is  no  longer  any  reasonable 
doubt  that  congenital  displacement  of  the  hip  is  due  to  a 
malformation  of  the  acetabulum,  due  to  developmental 
errors  in  its  iliac  segment.  Secondary  changes  occur  in 
the  head  of  the  femur,  and  it  is  never  caused  by  injuries 
at  birth,  as  was   formerly  maintained  by  nearly  all  sur- 


CONGENITAL    DISPLACEMENTS 


247 


geons.  The  displacement  is  more  often  bilateral  than 
unilateral,  and  in  88  per  cent,  of  the  cases  it  occurs  in 
girls. 


Fig.  26. 


Fig.  27. 


Figs.  26,  27.— Single  and  double  congenital  displacement  of  the  hip.     The 
case  of  single  displacement  is  copied  by  permission  from  Mr.  Adams'  work. 

Symptoms. — The  defect  is  not  usually  discovered  until 
the  child  begins  to  walk.     Attention  is  then  called  to  it 


248      THE    SURGICAL    DISEASES    OF    CHILDREN 

by  the  peculiar  gait  which  is  acquired  owing  to  the  play 
of  the  head  of  the  femur  upon  the  dorsum  ilii  inside  the 
elongated  capsule.  This  leads  to  a  rolling,  waddling  move- 
ment if  the  displacement  is  double,  for  at  each  step  the 
body  is  inclined  towards  the  limb  upon  which  the  weight 
is  borne.  The  physical  examination  is  best  made  by  sit- 
ting behind  the  patient,  who  has  been  stripped.  It  will 
then  be  noticed  that  the  buttocks  are  unduly  wide,  that 
the  great  trochanter  is  raised  above  Nelaton's  line,  and  that 
the  child  presents  the  peculiar  form  of  lordosis  known  as 
"saddle-back"  (figs.  26,  27).  Mr.Barwell23  has  recently 
shown  that  when  the  patient  bends  forward  with  the  knees 
straight  the  trochanter  on  the  affected  side  projects  up- 
wards above  all  the  other  bony  points  of  the  pelvis  in  an 
absolutely  unmistakable  manner.  A  further  examination 
may  next  be  made  in  a  recumbent  position.  It  will  then 
be  found  that  the  affected  leg  is  shortened,  but  that  the 
shortening  can  readily  be  overcome  by  pulling  upon  it, 
though,  as  soon  as  the  extending  force  is  taken  off,  the 
head  again  ascends  and  assumes  its  original  position,  which 
is  usually  above  and  behind  the  acetabulum.  A  slight 
jerk  will  often  be  felt  as  the  femur  passes  over  the  sur- 
face of  the  ilium,  as  though  it  were  moving  along  an 
irregular  surface. 

Diagnosis. — Congenital  displacement  has  to  be  dis- 
tinguished from  the  weak  joint  associated  with  infantile 
paralysis  or  unnoticed  septic  arthritis  occurring  in  connec- 
tion with  one  of  the  exanthemata  ;  but,  as  a  rule,  there  is 
not  the  least  difficulty  in  recognising  a  congenital  dis- 
placement if  attention  be  paid  to  the  history  and  to  the 
symptoms. 

Prognosis. — The  prognosis  is  at  present  very  unsatis- 
factory, for  no  method  of  treatment  has  yet  succeeded  in 
giving  a  perfect  limb,  though  all  methods  claim  to  improve 


CONGENITAL    DISPLACEMENTS  249 

a  condition  which  in  its  slighter  forms  is  only  incon- 
venient. 

Treatment. — Many  methods  of  treatment  have  been 
adopted.  They  may  he  divided  into  operative  and  ex- 
pectant. The  most  recent  operative  method  is  that  carried 
ont  by  Lorenz. 

The  limb  being  extended,  he  divides  the  adductors  sub- 
cutaneously.  Through  the  same  incision  the  hamstrings 
are  likewise  detached  from  the  tuberosity  of  the  ischium. 
An  incision  between  two  and  three  inches  long  is  then 
made  from  the  anterior  superior  spine  of  the  ilium  vertically 
downwards.  This  enables  the  operator  to  divide  the  fascia 
lata,  tensor  fasciae  femoris,  the  anterior  edge  of  the  gluteus 
medius  and  the  sartorius  in  a  transverse  direction.  Passing 
more  deeply  between  the  tensor  fascise  and  the  sartorius, 
he  introduces  a  director  under  the  tendon  of  the  rectus 
femoris,  which  he  divides  immediately  below  the  anterior 
inferior  spine  of  the  ilium. 

The  anterior  aspect  of  the  capsule  having  been  exposed, 
the  joint  is  opened  by  a  crucial  incision.  Extension  is 
now  relaxed,  the  thigh  flexed  and  adducted,  and  the  femur 
forced  upwards  so  as  to  bring  the  head  into  contact  with 
the  acetabulum.  At  this  stage  of  the  operation  it  is  im- 
portant to  divide  with  a  probe-pointed  knife  a  few  tense 
bands  from  the  capsule  which  are  inserted  into  the  neck 
of  the  bone.  When  this  is  done,  the  acetabulum  can  be 
reached  and  even  seen  by  separating  the  edges  of  the 
opening.  The  cotyloid  cavity  is  now  enlarged,  care  being 
taken  to  preserve  the  bony  rim  intact  above  and  behindhand 
a  little  extension  brings  the  head  opposite  the  acetabulum, 
into  which  it  readily  glides.  The  operation  is  completed 
by  closure  of  the  external  wound,  except  in  its  middle  part, 
which  remains  open.  Lastly,  an  apparatus  is  applied  which 
maintains  the  thigh  in  a  position  of  slight  abduction. 


25O      THE    SURGICAL    DISEASES    OF    CHILDREN 

This,  like  all  other  operative  measures,  is  only  indicated 
for  patients  between  the  ages  of  4  and  7  years  of  age,  as  a 
cutting  operation  is  difficult  and  dangerous  in  older  chil- 
dren. Division  of  the  femur  below  the  trochanter  is 
serviceable  for  older  children  when  there  is  extreme  de- 
formity of  the  hip  with  adduction.  Hoffa's  operation 
may  also  be  adopted  in  these  cases.  The  head  of  the 
bone  is  sawn  off  at  the  intertrochanteric  line  in  his 
operation,  the  posterior  part  of  the  capsule  is  cut  away  in 
order  to  allow  of  good  apposition  of  the  limb,  which  is 
then  put  up  in  a  plaster  case  in  an  abducted  position. 
When  the  displacement  is  unilateral  and  only  slight  in 
degree,  it  may  be  sufficient  to  conceal  the  shortening  by 
the  use  of  some  form  of  high  boot.  Lannelongue's  method 
of  sclerogeny  (p.  102)  is  sometimes  serviceable  when  the 
range  of  movement  is  unduly  extensive.  The  treatment 
of  these  cases  by  prolonged  rest  with  extension  has  found 
many  advocates,  either  in  its  simplest  form,  as  has  been 
advocated  by  Buckminster  Brown  and  by  Mr.  William 
Adams  (to  whose  kindness  I  am  indebted  for  fig.  26),  or 
in  its  abridged  form  by  division  of  the  tendons  and  by 
endeavouring  to  form  a  new  acetabulum.  The  method  of 
absolute  recumbency  for  two  or  three  years,  followed  by 
the  use  of  instruments  to  secure  the  immobility  of  the 
hip  for  a  further  period  of  eighteen  months,  sometimes 
yield  satisfactory  results  if  it  be  adopted  for  children  of 
two  or  three  years  old. 

Congenital  Displacement  of  the  Tibia. 

Congenital  displacement  of  the  knee  is  less  frequent  than 
a  similar  condition  in  the  hip.  Of  the  twenty-six  recorded 
cases,  Hoffa  says  that  fifteen  were  double,  and  of  the  rest 
nine  were  on  the  left  side  and  onlv  two  were  on  the  right. 
Both  sexes  are  equally  affected,  and  there  is  no  evidence  of 


CONGENITAL    DISPLACEMENTS  25  I 

any  hereditary  predisposition.  The  tibia  is  nearly  always 
dislocated  forwards,  for  only  in  a  single  instance  did  it  lie 
behind  the  femur.  There  is  no  difficulty  in  recognising 
the  condition,  though  it  must  not  be  mistaken  for  the 
back-knee,  which  results  from  defective  growth  at  the 
epiphyseal  lines,  and  is  often  connected  with  infantile  para- 
lysis. Congenital  absence  of  the  patella  has  been  noticed 
in  a  few  cases  of  congenital  dislocation  of  the  knee.  The 
prognosis  is  good  when  the  affection  is  unilateral. 

Treatment. — The  dislocation  should  be  reduced  and 
the  leg  should  be  fixed  in  a  plaster  case  extending  above 
the  knee  for  a  week.  Massage  and  passive  movement 
should  then  be  commenced,  the  splint  being  removed  daily 
until,  at  the  end  of  a  fortnight,  it  can  be  entirely  laid 
aside. 

Passive  Dislocations  of  the  Fibula.21 

The  upper  end  of  the  fibula  is  sometimes  dislocated, 
either  completely  or  incompletely,  in  children.  The  head 
of  the  bone  is  usually  displaced  outwai'ds,  and  although  it 
is  readily  replaced,  it  is  as  readily  dislocated  again. 

The  condition  appears  to  be  due  to  knock-knee,  when  it 
is  only  accidentally  discovered,  or  it  may  result  from  in- 
jury. It  may  be  due  to  congenital  defects,  to  weakness  of 
the  ligaments,  or  to  infantile  paralysis  of  the  quadriceps. 

The  signs  are  obvious,  the  symptoms  less  well  defined ; 
for  the  child  walks  easily,  but  is  apt  to  stumble. 

The  treatment  must  depend  upon  the  cause.  The  knock- 
knee  must  be  corrected,  and  it  may  be  necessary  to  suture 
any  ligaments  which  have  been  torn  in  cases  following 
upon  an  injury  to  the  knee. 

Congenital  Displacement  of  the  Patella. 
The  knee-cap  is  sometimes  displaced  congenitally.     It  is 


2^2      THE    SURGICAL    DISEASES    OF    CHILDREN 

always  outwards,  and  is  generally  associated  with  knock- 
knee.  Heredity  appears  to  play  a  great  part  in  its  pro- 
duction. Its  treatment  is  unsatisfactory,  but  an  attempt 
may  be  made  to  remedy  the  defect  resulting  from  the 
deformity  by  the  application  of  a  light  outside  iron  splint 
with  a  pelvic  band. 

Congenital  Displacement  of  the  Elbow. 

Congenital  displacement  of  the  elbow  is  very  rare. 
Both  bones  may  be  dislocated  backwards  or  forwards,  or 
the  radius  alone  may  be  displaced,  though  this  is  exceed- 
ingly rare.  Excision,  either  of  the  joint  or  of  the  head 
of  the  radius,  may  be  performed  in  very  severe  cases. 

Congenital  Displacement  of  the  Shoulder. 

Congenital  displacement  of  the  shoulder  is  of  unusual 
occurrence,  for  most  of  the  recorded  cases  have  been  met 
with  in  adults,  and  there  is  reason  to  suppose  that 
they  were  of  paralytic  origin.  The  dislocation  in  the 
undoubted  cases  has  either  been  of  the  subcoracoid  or 
subacromial  variety,  whilst  in  one  of  Gruerin's  cases  the 
head  of  the  humerus  was  displaced  upwards  and  outwards. 
Graillard  has  seen  a  girl  whose  humerus  was  observed  to 
be  displaced  a  few  days  after  birth.  At  sixteen  years  of 
age  she  was  found  to  have  developed  an  infraspinous  dis- 
location, with  fixation  and  much  wasting  of  the  shoulder. 
Treatment  is  ineffectual. 


CHAPTER  XII 

SURGICAL    AFFECTIONS    OF   THE    LIPS, 
MOUTH,   TONGUE,   AND   (ESOPHAGUS 

Harelip. 

Varieties. — Harelip  is  either  partial  or  complete,  single 
or  double.  It  may  or  may  not  be  associated  with  a  cleft 
palate,  and  in  cases  of  double  harelip  there  may  be  marked 
alteration  in  the  position  and  relation  of  the  intermaxillary 
bones,  and  of  the  alse  nasi.  In  some  more  rare  cases  the 
cleft  is  median,  in  others  it  is  a  cleft  of  the  lower  lip, 
and  in  yet  others  the  cleft  is  lateral  and  extends  into  the 
cheek,  constituting  a  condition  of  macrostoma.  The  recog- 
nition of  harelip  presents  no  difficulties,  and  the  only 
questions  that  arise  in  connection  with  it  are,  when  and 
how  it  shall  be  cured.  Feeble  children  who  are  wasting 
daily  in  spite  of  their  being  able  to  suck,  the  surgeon  will 
have  nothing  to  do  with ;  syphilitic  babies  come  into  the 
same  category,  and  so  do  those  who  have  thrush,  diarrhoea, 
or  bronchitis.  The  operation  in  each  case,  however,  may  be 
performed  as  soon  as  the  child's  health  is  restored.  Wasting 
babies  are  often  rapidly  improved  by  forced  feeding.  This 
is  best  effected  by  passing  an  inch  and  a  half  or  two 
inches  of  india-rubber  tubing  to  the  back  of  the  mouth 
and  connecting  the  other  end  with  a  glass  syringe.  The 
syringe,  filled  with  liquid  food,  is  worked  rhythmically  to 
imitate  the  discharge  of  milk  from  the  nipple. 


254      THE    SURGICAL    DISEASES    OF    CHILDREN 

Time  for  Operating.— The  best  time  for  the  operation 
is  during  the  fourth  month,  for  the  child  is  then  strong 
and  well  able  to  bear  the  loss  of  blood,  whilst  it  is  suffi- 
ciently far  from  the  commencement  of  the  teething  period 
to  prevent  any  anxiety  on  that  score.  When  it  is  impos- 
sible for  the  child  to  get  sufficient  food  owing  to  its 
inability  to  suck,  and  when  it  is  otherwise  healthy,  it  may 
be  necessary  to  operate  earlier ;  but  such  cases  are  very 
rare,  and  much  depends  upon  the  nurse. 

Operation. — The  mouth,  gums,  and  nose  must  be 
thoroughly  cleansed  before  the  operation,  by  means  of  small 
pledgets  of  absorbent  wool  soaked  in  a  saturated  solution 
of  boric  acid.  The  child  is  then  wrapped  up  in  a  sheet  to 
prevent  it  raising  its  arms  during  the  operation,  and  it  is 
anaesthetised.  The  assistant  stands  upon  the  left  side  of 
the  patient,  and  takes  the  lip  upon  either  side  of  the  cleft, 
between  the  finger  and  thumb  of  each  hand,  in  such  a 
manner  as  to  compress  the  inferior  coronary  arteries  and  so 
to  arrest  the  bleeding.  The  surgeon  then  everts  the  lip, 
and  with  a  thin  scalpel  separates  its  outer  portion  very 
freely  from  the  cheek  by  cutting  through  the  mucous 
membrane  until  the  sides  of  the  cleft  can  readily  be  ap- 
proximated ;  but  if  possible  he  leaves  the  central  edge  of 
the  cleft  and  the  frsenum  of  the  lip  untouched.  A  piece 
of  sponge  on  a  holder  is  then  pressed  between  the  cheek 
and  the  bone  to  arrest  the  haemorrhage,  and  a  fresh  supply 
of  chloroform  is  administered  to  the  patient. 

The  operator  then  takes  a  pair  of  toothed  forceps  in  his 
left  hand,  and  with  the  scalpel  in  his  right,  he  proceeds 
to  pare  the  edges  of  the  cleft  upon  both  sides,  taking  care 
to  pare  the  angle  in  a  simple  cleft,  and  to  carry  his  incision 
well  up  into  the  nose  in  the  complete  form.  The  paring 
should  be  liberal,  and  must  include  the  whole  of  the  red 
surface  of   the  lip.     The  edge  should  be   completely  cut 


HARELIP  255 

away  on  the  central  border,  but  it  should  not  be  detached 
upon  the  cheek  side,  where  it  should  be  left  as  a  flap. 

The  edges  of  the  cleft  are  approximated  at  once,  so  that 
the  two  borders  of  the  lip  are  in  exact  apposition,  and  a 
suture  of  silver  wire  is  passed  through  the  whole  thickness 
of  both  sides  of  the  cleft,  at  the  point  where  the  two 
arteries  have  been  cut,  to  arrest  the  haemorrhage.  Horse- 
hair sutures  are  then  put  into  the  lip  above  and  below  the 
wire  suture,  so  as  to  bring  the  edges  into  accurate  contact. 
The  flap  attached  to  the  outer  side  of  the  cleft  is  then 
brought  over  the  lip  upon  the  inner  side,  and  for  this 
purpose  the  free  border  of  the  lip  upon  this  side  has 
been  freshened.  It  is  secured  by  a  horsehair  suture. 
The  notch  which  sometimes  appears  after  the  operation  for 
harelip  can  in  this  way  often  be  prevented  from  appearing. 

The  lip  is  gently  dried,  and  a  piece  of  cyanide  gauze 
shaped  like  the  figure  00  is  cemented  over  it  with  collodion, 
a  piece  of  strapping  being  applied  over  the  whole  to  keep 
it  firm.  The  wound  usually  requires  dressing  on  the  third 
day,  and  it  sometimes  happens  that  union  is  so  complete  as 
to  enable  the  sutures  to  be  removed ;  more  often,  however, 
they  must  be  left  in  position  from  four  to  seven  days, 
though  it  is  better  to  remove  them  as  soon  as  possible. 

Modifications. — The  above  is  the  simplest  operation, 
but  it  is  rarely  performed  in  its  naked  simplicity,  for  no 
two  cases  of  harelip  are  alike,  and  the  surgeon  is  called 
upon  to  exercise  his  ingenuity  as  often  in  this  operation  as 
in  any  other  plastic  procedure.  When  the  cleft  is  complete, 
the  nose  is  often  much  flattened,  and  it  must  be  dealt  with 
before  any  operation  is  performed  upon  the  lip.  Mr.  Thomas, 
of  Birmingham,  has  recently  introduced  a  slight  modifica- 
tion in  the  treatment  of  these  cases,  which  is  often  very 
useful.  The  first  step  in  his  operation  consists  in  restoring 
the  margin  of  the  nostril,  by  freeing  the  outer  edge  of  the 


256      THE    SURGICAL    DISEASES    OF    CHILDREN 

ala  nasi,  and  attaching  the  edge  of  its  cartilage  to  the 
columna  nasi.  An  interval  is  then  allowed  to  elapse  until 
union  is  complete,  and  the  ordinary  operation  is  then  per- 
formed. 

The  most  troublesome  cases  of  harelip  are  those  in  which 
the  cleft  is  wide  and  has  uneven  margins,  or  those  in 
which  the  premaxillse  are  displaced  ;  for  a  double  harelip  is 
not  necessarily  more  difficult  to  close  than  a  single  one. 
The  surgeon  has  to  be  guided  to  a  certain  extent  by  the 
necessities  of  each  case,  as  no  hard-and-fast  rule  can  be  laid 
down  for  the  treatment  of  the  premaxillse.  The  broad  rule 
is  that  they  must  be  saved  as  often  as  possible,  when  their 
retention  does  not  militate  against  good  union  of  the  lip  on 
the  one  hand,  or  against  the  prominence  of  the  alse  nasi  on 
the  other.  It  sometimes  happens  that  if  undue  force  be 
exerted  to  twist  and  maintain  them  in  good  position,  the 
tip  of  the  nose  may  be  unduly  flattened;  whilst,  on  the 
other,  if  they  be  ruthlessly  cut  away  on  every  occasion, 
an  unsightly  and  square  upper  lip  is  produced.  If  the 
mass  is  attached  to  the  tip  of  the  nose,  it  had  better  be 
removed  after  its  covering  of  mucous  membrane  has  been 
turned  downwards  to  enable  it  to  be  utilized  at  a  later 
stage  in  the  operation. 

Kronlein's  suture  should  be  employed  when  the  tissue 
is  deficient,  when  an  undue  strain  is  put  upon  it,  or  when 
from  any  cause  union  by  first  intention  has  failed,  and  it 
is  necessary  to  obtain  adhesion  by  granulation.  A  piece 
of  stout  silver  wire  is  threaded  through  a  pearl  shirt- 
button  which  has  been  boiled  to  render  it  aseptic,  its  free 
end  is  passed  with  a  needle  through  the  cheek  just  beneath 
the  malar  bone,  and  then  transversely  across  the  gum  to 
an  exactly  corresponding  point  beneath  the  opposite  malar, 
where  it  is  threaded  to  a  second  button  and  drawn  suffi- 
ciently tight  to  keep  the  two  borders  of  the  cleft  in  good 


HARELIP  257 

apposition.  A  useful  tension  suture  is  thus  obtained,  and 
if  the  silver  wire  is  thick  enough,  it  may  be  left  in  position 
without  producing  any  suppuration  until  good  union  is 
obtained,  and  it  only  leaves  two  pinhole  scars  which  are 
hardly  noticeable. 

It  is  often  a  mistake  to  try  and  do  too  much  at  a  single 
operation  upon  a  harelip,  for  the  child  becomes  collapsed, 
or  unduly  weakened  by  loss  of  blood,  and  the  tissues  do 
not  then  repair  by  first  intention.  It  is  better  to  perform 
two  or  three  operations  in  severe  cases,  and  except  in  the 
simplest  forms,  a  secondary  operation  is  very  frequently 
required. 

After-Treatment. — The  after-treatment  consists  in 
keeping  the  child  quiet  and  in  not  permitting  it  to  cry. 
It  should  be  fed  from  a  feeding-bottle  which  allows  the 
fluid  to  be  drawn  up  easily.  Mr.  Jacobson  and  Mr. 
Wright  have  both  drawn  attention  to  the  urgent  dysp- 
noea, even  to  asphyxia,  which  sometimes  occurs  after  the 
operation  for  harelip.  It  is  due  apparently  to  a  valvular 
action  of  the  lower  lip,  preventing  the  entrance  of  air  into 
the  lungs  of  a  child  who  has  not  yet  learnt  to  breathe 
through  its  nose.  The  dyspnoea  comes  on  suddenly,  and 
the  condition  is  a  relapsing  one.  It  is  rare,  fortunately, 
for  it  is  so  fatal  that  each  of  the  three  recorded  cases  died. 
No  child,  therefore,  who  has  been  operated  upon  for  a 
harelip,  should  be  left  without  the  supervision  of  a  nurse. 
She  must  be  instructed  to  depress  the  lower  lip,  at  inter- 
vals of  ten  minutes  for  an  hour  or  two  after  the  operation, 
to  enable  the  child  to  obtain  plenty  of  air  by  its  mouth,  if 
it  presents  symptoms  of  dyspnoea.  She  ought  also  to  be 
shown  how  to  maintain  artificial  respiration,  and  she  must 
be  told  instantly  to  send  for  assistance  if  the  child  becomes 
livid. 


258      THE    SURGICAL    DISEASES    OF    CHILDREN 

CLEFT  PALATE. 

Varieties. — Congenital  clefts  of  the  palate  may  or  may 
not  be  associated  with  harelip.  Clefts  of  the  hard  palate 
are  always  associated  with  clefts  of  the  soft  palate  ;  but 
the  soft  palate  is  sometimes  cleft,  whilst  the  hard  palate  is 
normal.  Cleft  palate  in  the  early  life  of  a  child  causes 
trouble  in  deglutition,  and  in  later  life  speech  is  altered. 
The  earlier  difficulties  can  be  overcome  by  allowing  the 
child  to  suck  from  a  bottle  with  a  very  large  nipple,  or 
from  one  in  which  the  nipple  has  attached  to  it  a  soft 
metal  cover  (fig.  28)  serving  as  an  obturator,  or  by  careful 
feeding  with  a  half-decked  spoon.     The  later  difficulties 


Fig.  28.— Nipple,  with  flexible  metal  shield,  for  the  use  of  infants  with  cleft 
palate. 

are  partially  removed  by  repairing  the  defect  before  the 
child  has  learnt  to  talk. 

Time  for  Operation.— The  operation  should  therefore 
be  performed  when  the  child  is  about  three  years  of  age  ; 
but  the  harelip,  if  it  be  present,  should  be  repaired  at  the 
ordinary  time,  as  its  closure  appears  to  exercise  some 
degree  of  traction  upon  the  two  inaxillse,  and  so  prevents 
undue  widening  of  the  cleft,  if  it  does  not  actually  tend  to 
close  it. 

The  Operation.— The  tonsils,  if  they  are  unduly  en- 
larged, should  be  removed  before  the  operation  is  undertaken. 
The  child  otherwise  needs  but  little  preparatory  treatment 
beyond  the  ordinary  purge  and  the  application  of  an  anti- 
septic  solution   to   the   mouth   and   naso-pharynx.      The 


CLEFT     PALATE  259 

patient  is  anaesthetised,  and  is  so  placed  upon  the  operating 
table  that  his  head  hangs  vertically  over  the  end,  in  the 
manner  recommended  by  Professor  Rose,  of  Berlin.  The 
table  must  be  arranged  to  get  the  best  possible  light  upon 
the  mouth,  for  it  is  of  the  utmost  importance  that  the 
surgeon  should  see  quite  clearly  every  part  of  its  roof.  A 
skilled  anaesthetist  is  very  necessary  in  cases  of  cleft 
palate ;  for  the  ease  of  the  operation,  and  often  a  great  part 
of  its  success,  will  materially  depend  upon  his  abilities. 

A  gag  is  introduced  into  the  side  of  the  mouth,  and  the 
simpler  the  pattern  the  better ;  it  is  taken  charge  of  by  the 
assistant,  who  stands  upon  the  left  side  of  the  patient, 
whilst  the  operator  stands  upon  the  right  side.  He  then 
takes  a  narrow-bladed  scalpel  fixed  into  a  long  handle,  and 
with  it  he  makes  an  incision  upon  either  side  of  the  palate, 
external  to  the  descending  palatine  artery,  and  reaching 
from  the  anterior  angle  to  the  posterior  border  of  the  cleft 
in  the  palate.  The  mucous  membrane,  with  its  glands 
and  the  periosteum,  are  then  raised  with  a  raspatory  upon 
either  side,  and  along  the  whole  length  of  the  incision,  so 
that  the  two  flaps  hang  loosely,  and  can  readily  be  brought 
together  along  the  middle  line.  This  stage  in  the  opera- 
tion is  attended  by  much  bleeding,  and  it  is  an  important 
part  of  the  assistant's  duty  to  prevent  the  blood  passing 
into  the  trachea ;  for  this  purpose  he  is  provided  with 
numerous  small  pieces  of  surgically-clean  sponge,  mounted 
on  holders.  The  whole  depth  of  tissue  down  to  the  bone 
must  be  taken  up  in  the  flaps,  and  their  thickness  is  often 
a  matter  of  surprise. 

As  soon  as  the  flaps  have  been  detached,  a  piece  of  sponge 
is  held  lightly  against  them  in  such  a  manner  as  to  com- 
press them  against  the  palate,  whilst  a  fresh  supply  of 
chloroform  is  administered  to  the  patient.  The  bleeding 
soon  stops,  and  the  surgeon  then  proceeds  to  pare  the  edges 


260      THE    SURGICAL    DISEASES    OF    CHILDREN 

of  the  cleft.  He  seizes  the  extremity  of  one  side  of  the 
uvula  with  a  pair  of  long-handled  forceps,  and  makes  one 
side  of  the  cleft  tense.  He  then  enters  a  sharp-pointed  and 
thin  knife,  which  may  be  double-edged  if  he  prefer  it,  close 
to  the  margin  of  the  cleft,  and  pares  the  whole  of  one  side ; 
the  other  end  of  the  uvula  is  then  stretched,  and  the  pro- 
ceeding is  repeated  upon  the  opposite  side,  especial  care 
being  taken  to  freshen  the  anterior  angle  of  the  cleft  and 
the  tips  of  the  uvula.  Professor  W.  Rose,  of  King's  Col- 
lege, who  has  had  very  great  experience  in  performing  the 
operation,  strongly  recommends  that  the  mucous  membrane 
should  be  cut  away  in  a  single  strip,  so  as  to  ensure  its 
complete  removal.  It  is  enough  to  freshen  the  edge  if  the 
incision  be  made  square,  and  in  no  case  should  it  be 
bevelled.  Every  fragment  of  tissue  in  an  operation  for 
cleft  palate  is  of  importance,  so  that  no  more  should  be 
removed  than  is  absolutely  necessary. 

In  simple  cases,  when  the  edges  of  the  flap  come  to- 
gether readily  in  the  middle  line,  the  sutures  may  be 
inserted  at  once  ;  but  if  there  is  the  least  tension  upon 
them,  it  is  better  to  pass  underneath  the  palate  a  pair  of 
blunt-pointed  scissors  curved  upon  the  fiat,  and  to  cut 
transversely  so  as  to  divide  the  attachment  of  the  palate 
to  the  posterior  border  of  the  palate  bone.  Professor  W. 
Rose  relieves  the  lateral  tension  by  dividing  the  levator 
palati.  "  A  narrow-bladed  and  probe-pointed  bistoury  is 
introduced  through  the  lateral  aperture  in  the  palate  upon 
either  side,  and  is  carried  directly  backwards  through  the 
soft  palate."  The  tip  of  the  uvula  is  first  united  by  a 
horsehair  suture  introduced  by  a  curved  or  rectangular 
needle  fixed  into  a  handle,  and  care  must  be  taken  to  get- 
exact  approximation  of  the  two  points,  so  that  the  uvula 
should  not  afterwards  look  bifid.  The  suture  is  tied  in  a 
reef  knot,  and  is  left  long.     Its  ends  are  then  seized  in  a 


CLEFT     PALATE 


26l 


pair  of  long  dissecting  forceps,  and  they  are  pulled  back- 
wards towards  the  pharynx  until  the  uvula  is  stretched ; 
a  second  horsehair  suture  is  then  introduced  into  the 
uvula  and  tied,  and  its  ends  are  cut  off.  Three  sutures 
are  generally  sufficient. 

The  main  sutures  in  the  muco-periosteurn  of  the  hard 
palate  should  be  of  silver  wire  (No.  30  or  32  gauge).  They 
are  introduced  from  behind  forwards,  one  at  the  base  of 
the  cleft,  a  second  about  the  middle,  and  the  third   an- 


Fig.  29. — Diagrams  showing  the  old  method  of  inserting  sutures  in  the 
operation  of  cleft  palate  (the  left-hand  figure),  and  the  method  recommended 
by  Professor  W.  Rose  (the  right-hand  figure). 

[Copied  by  permission  from  Prof.  Rose's  work  on  Cleft  Palate  and  Harelip.] 

teriorly.  Personally,  I  always  use  Mr.  Thomas  Smith's 
tubular  needle,  but  many  surgeons  employ  angular  needles 
fixed  in  a  handle.  The  wire  sutures  should  not  be  drawn 
together  until  the  secondary  sutures  have  been  introduced. 
The  secondary  sutures  are  of  horsehair,  and  Professor  W. 
Rose  has  shown  that  much  better  results  are  obtained  when 
they  are  introduced  by  needles,  whose  cutting  edge  is  at 
right  angles,  instead  of  lying  parallel  to  the  edge  of  the  cleft 
like  those  generally  made,  as  will  be  seen  in  the  annexed 


262      THE    SURGICAL    DISEASES    OF    CHILDREN 

diagram  (fig.  29).  As  soon  as  all  the  sutures  are  passed, 
the  ends  of  the  one  in  the  uvula  are  cut  short,  the  wire 
sutures  are  twisted  up,  the  anterior  one  first,  then  the 
middle,  and  finally  the  posterior  one.  The  horsehair 
sutures  are  then  tied  off,  and  in  a  nicely  finished  operation 
the  united  cleft  should  appear  as  a  single  line  running 
straight  fore  and  aft  without  any  puckering.  In  tying 
the  sutures,  care  should  be  taken  that  the  edges  of  the 
wound  do  not  become  inverted. 

When  it  is  doubtful  whether  the  hard  or  the  soft  palate 
should  be  closed,  it  is  better  to  operate  upon  the  hard 
palate  first ;  but  when  it  is  possible,  the  whole  palate 
should  be  closed  by  a  single  operation.  The  cleft  is  some- 
times so  large  that  it  is  impossible  to  close  it  by  the  ordi- 
nary linear  incision,  and  Mr.  Davies  Colley  has  recently 
recommended  an  operation  by  means  of  flaps  for  these  cases. 
The  cleft  again  may  be  so  large  that  no  operative  measures 
will  close  it,  and  such  cases  must  be  sent  to  the  dentist  to 
be  provided  with  some  form  of  obturator. 

Dangers  of  the  Operation. — No  serious  danger  at- 
tends the  actual  operation  for  cleft  palate,  if  the  pharynx 
be  kept  clear  of  blood  ;  but  serious  haemorrhage  from  the 
descending  palatine  artery  may  occur  as  late  as  the  ninth 
day,  as  in  a  case  which  I  reported  in  the  British  Medical 
Journal  for  1894.  When  this  happens,  the  wound  should 
be  carefully  explored  in  a  good  light,  if  ice  and  the  ordinary 
measures  fail  to  check  the  blood-flow,  and  an  endeavour 
should  be  made  to  secure  the  bleeding  point.  Haemorrhage, 
both  immediate  and  remote,  is  due  to  puncture  or  partial 
injury  of  one  of  the  main  trunks  of  the  descending  palatine 
artery ;  and  if  it  occurs  at  the  time  of  the  operation,  the 
trunk  must  be  completely  divided,  as  the  collateral  circula- 
tion is  so  free  that  there  is  no  risk  of  the  flap  sloughing. 

After-Treatment.  —  The  after-treatment    consists    in 


CLEFT     PALATE  263 

keeping  the  patient  very  quiet,  silent,  and  with  his  head 
low.  Food  should  not  be  given  for  three  hours  after  the 
operation,  and  only  sparingly  for  twenty-four  hours. 
Spoonfuls  of  warm  milk  and  water  may  then  be  given  at 
frequent  intervals,  with  soups  or  jelly.  Bread  and  milk 
may  be  given  on  the  seventh  day,  but  hard  food  should  be 
withheld  for  at  least  a  [fortnight.  The  sutures  may  be 
removed  in  a  fortnight  or  three  weeks,  the  silver  sutures 
being  removed  last.  After  each  meal  the  mouth  should 
be  gargled  with  a  1  in  40  solution  of  warm  boric  acid 
solution. 

Secondary  Operations.— Some  part  of  the  cleft  often 
remains  unclosed,  or,  more  rarely,  the  operation  may  be  a 
total  failure.  When  a  small  sinus  alone  exists,  it  should 
be  left  untouched  for  a  time,  as  it  occasionally  closes  spon- 
taneously during  the  process  of  cicatrisation.  If  it  fails 
to  close,  it  may  be  touched  with  the  point  of  a  Paquelin's 
cautery.  When  the  unclosed  part  is  larger,  a  repetition  of 
the  original  operation  may  be  required. 

EPITHELIOMA   OF   THE  LIP. 

Epithelioma  of  the  lip  occurs  in  children  as  a  patho- 
logical curiosity,  with  the  same  characters,  running  the 
same  course,  and  requiring  the  same  treatment  as  in 
adults. 

BANULA. 

Banula  occurs  either  congenitally,  as  a  cystic  formation 
in  connection  with  the  glands  of  Nuhn,  or  due  to  blocking 
of  one  of  the  mucous  follicles  in  the  floor  of  the  mouth. 
The  tumour  derives  its  name  from  a  fancied  resemblance 
to  the  guttural  pouches  in  the  frog.  It  is  either  placed 
laterally,  or  it  may  extend  over  the  whole  floor  of  the 
mouth. 


264      THE    SURGICAL    DISEASES    OF    CHILDREN 

Diagnosis. — The  ranula  must  be  distinguished  from  a 
dermoid  cyst  in  the  same  region.  The  mucous  membrane 
in  a  ranula  is  so  thin  that  the  fluid  can  be  seen  beneath  it, 
and  is  glairy  ;  whilst  in  a  dermoid  the  covering  is  too 
thick  to  allow  the  more  solid  contents  of  the  cyst  to  be 
visible.  The  diagnosis  between  a  ranula  and  some  forms 
of  congenital  cyst  in  the  floor  of  the  mouth  can  only  be 
made  by  a  microscopical  examination  of  the  wall,  when 
the  cyst,  if  it  has  been  developed  from  the  lower  part  of 
the  thyreo-glossal  duct,  will  be  found  to  be  lined  with 
ciliated  epithelium. 

Treatment. — A  radical  operation  should  be  performed 
as  far  as  possible  by  extirpating  the  cyst,  for  puncture  and 
injection  of  iodine  do  not  give  very  satisfactory  results. 
If  the  entire  cyst  cannot  be  removed,  the  mucous  mem- 
brane is  fixed  with  a  pair  of  forceps,  and  incised.  A  large 
opening  is  then  made  into  the  cyst  wall  by  the  removal 
of  a  portion  of  the  mucous  membrane.  The  ranula  thus 
treated  cicatrises,  and  quickly  heals. 

THE  TONGUE. 

Injuries,  ulcers,  and  new  growths  are  as  common  in  the 
tongues  of  children  as  they  are  in  adults. 

Injuries. 

Children  sometimes  fall  with  the  tongue  between  the 
teeth,  and  so  inflict  serious  injury  upon  it. 

Treatment. — It  is  necessary  in  such  cases  to  put  in 
one  or  two  point-sutures  of  horsehair,  and  to  keep  the 
mouth  washed  out  with  an  antiseptic  solution.  Repair 
readily  takes  place. 

Glossitis. 
The   tongue  may   become  inflamed   spontaneously,   and 


DISEASES    OF    THE    TONGUE  265 

either  the  whole  of  the  organ  or  one  side  is  involved.  It 
does  not  suppurate,  and  the  inflammation  subsides  under 
local  treatment  in  the  course  of  a  few  days.  Some  in- 
duration may  be  left. 

Abscess  of  Tongue. 

Abscesses  of  the  tongue  are  not  unusual ;  they  are  uni- 
lateral, and  may  be  so  chronic  as  to  lead  to  their  being 
mistaken  for  some  form  of  new  growth.  They  are  some- 
times tuberculous,  but  I  think  they  are  more  often  the 
result  of  injury. 

Treatment.— The  treatment  consists  in  laying  them 
open,  scraping  out  their  contents,  and  suturing  the  mucous 
membrane  to  obtain  union  by  first  intention. 

Mucous  Patches  of  Tongue. 

Mucous  patches  are  often  seen  in  young  children  who 
have  inherited  syphilis.  They  are  situated  upon  the 
dorsum  of  the  tongue,  and  at  the  corners  of  the  mouth. 

Treatment. — They  are  quite  amenable  to  treatment 
with  grey  powder,  and  local  antiseptic  applications  of 
glycerine  of  borax. 

Ulcers  of  Tongue. 

Various  forms  of  ulceration  occur.  The  most  common  is 
the  aphthous  ulcer,  either  commencing  as  a  patch  in  the 
ordinary  way,  or  as  a  group  of  vesicles  containing  a  clear 
fluid. 

Dyspeptic  ulcers  are  less  frequent.  They  have  a  small 
central  slough,  with  sharp-cut  edges  and  a  bright  red  zone 
round  them. 

Treatment.— Both  forms  may  be  cured  by  the  applica- 
tion of  the  glycerine  of  borax,  if  proper  attention  be  paid  to 
diet.  The  more  rebellious  ulcers  may  be  touched  with  a 
1  in  10  solution  of  chromic  acid. 


266      THE    SURGICAL    DISEASES    OF    CHILDREN 

Tuberculous  ulceration  is  seen  in  the  later  stages  of 
laryngeal  phthisis,  but  it  is  sometimes  primary.  The  ulcer 
is  usually  extensive,  and  is  most  often  situated  far  back 
upon  the  dorsum,  though  it  may  involve  the  whole  of  the 
mucous  membrane.  The  edges  are  sharply  defined,  and 
the  ulcerated  surface  may  have  a  characteristic  warty  and 
papillomatous  appearance  from  the  presence  of  small  yellow 
points. 

Treatment.  —  Palliative  measures  alone  can  be  em- 
ployed unless  the  ulceration  is  primary,  when  the  tongue 
may  be  scraped  with  a  sharp  spoon. 

Lupoid  ulceration  is  very  rare.  It  affects  the  anterior 
part  of  the  tongue,  and  is  generally  the  result  of  direct 
extension  from  the  lips. 

Treatment. — It  must  be  treated  by  scraping  away  the 
diseased  tissue. 

MICROGLOSSIA. 

etiology. — Microglossia  is  a  clinical  term,  embracing 
those  pathological  conditions  which  lead  to  enlargement 
of  the  tongue.  The  affection  is  usually  congenital,  and 
is  most  often  produced  by  venous  or  lymphatic  naevi,  and 
in  some  cases  by  a  combination  of  both  forms.  The  en- 
largement is  either  unilateral,  or  it  affects  the  whole 
tongue.  It  is  often  associated  with  epilepsy,  idiocy,  or 
other  mental  defects,  and  is  occasionally  found  associated 
with  endemic  or  sporadic  cretinism,  myxoedema,  and 
acromegaly.  Macroglossia  is  occasionally  traced  to  an 
injury,  or  to  chronic  or  acute  irritation  affecting  the 
superficial  parts  of  the  tongue.  The  enlargement  in  these 
cases  is  probably  associated  with  some  interference  with 
the  lymphatic  circulation  (see  also  p.  497). 

True  hypertrophy  of  the  several  tissues  of  the  tongue 
also  occurs  ;  but  it  is  much  less  frequent  than  the  older 


DISEASES    OF    THE    TONGUE  267 

writers  thought,  and  is  sometimes  part  of  a  unilateral 
enlargement  of  the  head,  or  even  of  the  whole  side  of  the 
body.  Tumours,  either  simple  or,  less  frequently,  malig- 
nant, may  lead  to  a  condition  of  macroglossia. 

Symptoms.— The  symptoms  are  unmistakable.  The 
mouth  is  always  open,  the  tongue  protrudes,  and  usually 
curves  downwards  from  the  tightness  of  the  frsenum,  lead- 
ing to  depression  and  eversion  of  the  lower  lip.  The  free 
salivation  accompanying  this  condition  usually  leads  to 
excoriation  of  the  lips. 

Treatment. — The  treatment  in  those  cases  where  the 
tongue  protrudes  to  only  a  small  extent  consists  in  the 
application  of  judicious  pressure  ;  in  other  cases  it  may  be 
necessary  to  remove  a  portion,  or  even  the  whole  tongue. 
Electrolysis  is  not  an  effective  method  of  treatment. 

Papilloma  and  Soft  Fibroma. 

Papillomata  and  soft  fibromata  are  not  very  unusual 
in  children.  They  are  situated  far  back  upon  the  dorsum 
of  the  tongue,  in  the  cases  I  have  seen  ;  but  I  do  not 
doubt  that  they  may  occur  at  any  part.  They  are  readily 
removed  with  a  pair  of  scissors.  They  occasionally  grow 
again. 

Lipoma. 

Lipomata  are  so  rare  in  the  tongue  as  to  be  pathological 
curiosities.     They  grow  in  the  substance  of  the  organ. 

Adenoma. 
Adenomata  or  glandular  tumours  grow  from  the  dorsum 
and  back  part  of  the  tongue.  They  are  occasionally 
cystic.  It  is  thought  that  they  may  be  accessory  thyroid 
glands,  for  they  are  found  to  have  a  structure  similar  to 
that  of  the  thyroid  gland.  Such  tumours  can  sometimes 
be  removed  by  a  snare,  but  they  usually  have  to  be  dis- 
sected out. 


268     THE    SURGICAL    DISEASES    OF    CHILDREN 

Malignant  Tumours. 

A  few  cases  of  sarcoma  of  the  tongue  are  recorded  as 
occurring  in  children,  but  they  are  excessively  rare. 

The  only  treatment  is  to  excise  that  portion  of  the  organ 
in  which  they  are  growing. 

Dermoids  and  Congenital  Cysts. 

Dermoids  and  congenital  cysts  of  the  tongue  and  neck 
are   considered  under  the   heading  of  congenital  defects 

(p.  512). 

Anchyloglossa. 

Anchyloglossa,  or  tongue-tie,  is  a  bugbear  of  many 
mothers,  though  it  is  not  of  very  frequent  occurrence.  The 
fear  is  clearly  a  relic  of  the  time  when,  as  Alexander  Read 
tells  us,  about  1634,  it  was  necessary  to  make  "  some 
just  animadversions  upon  the  temerity  of  midwives,  who 
always  wear  one  of  their  nails  of  a  great  length,  and 
being  thus  ready  with  an  incision  instrument  in  their 
hand,  wherever  they  come  to  do  their  office,  they  cut  the 
new-born  child's  tongue;  and  unless  they  did  this,  they 
believe  the  children  could  never  speak." 

etiology. — It  is  a  congenital  defect  caused  by  an 
undue  breadth  of  the  frsenum  linguae,  or  else  to  the  fact 
that  the  bridle  extends  too  far  forwards  towards  the 
alveolar  border  of  the  lower  jaw. 

Symptoms. — The  tip  of  the  tongue  is  drawn  down- 
wards, when  an  attempt  is  made  to  protrude  it,  and  the 
deformity  interferes  with  sucking. 

Treatment.— It  is  easily  remedied  by  slightly  snipping 
the  frsenum  with  blunt-pointed  scissors,  care  being  taken 
not  to  operate  upon  "  bleeders,"  and  to  keep  the  ends  of 
the  scissors  well  away  from  the  ranine  artery  which  runs 
along  the  base  of  the  tongue.    This  is  best  done  by  putting 


WOUNDS    OF    THE    MOUTH  269 

the  freenum  upon  the  stretch  with  the  fingers,  and  snipping 
towards  the  floor  of  the  month,  and  as  close  to  the  jaw  as 
possible,  as  if  to  remove  the  frsennm  from  the  floor  of  the 
mouth  and  not  from  the  tongue. 

WOUNDS   OF   THE  MOUTH. 

Children,  like  adults,  sometimes  sustain  penetrating 
wounds  of  the  mouth  and  pharynx  by  falling  whilst  they 
are  sucking  a  foreign  body.  A  careful  examination  should 
always  be  made  in  such  cases,  for  it  may  happen  that  a 
part  of  the  foreign  body  gets  impacted  in  the  soft  tissues, 
and  is  broken  off  so  short  that  digital  examination  will 
alone  reveal  its  presence.  The  body  may  remain  for  a 
long  time  undiscovered,  and  it  may  cause  severe  hsemor- 
rhage  by  the  ulceration  it  eventually  sets  up. 

The  following  case  is  a  good  instance  of  such  an  acci- 
dent. A  boy,  aged  two  years,  fell  on  his  face  whilst  he 
was  pretending  to  smoke  a  clay  pipe.  His  father  picked 
him  up,  and  seeing  the  pipe  sticking  out  of  his  mouth, 
drew  it  away,  but  did  not  notice  at  the  time  that  its  end 
was  broken.  There  was  a  wound  on  the  right  side  of  the 
mouth,  at  the  junction  of  the  upper  alveolar  arch  with 
the  palate,  which  bled  profusely  and  was  considerably 
swollen.  The  child  was  taken  to  a  hospital,  where  the 
wound  was  probed,  but  no  foreign  body  was  discovered. 
He  could  hardly  eat  anything  for  a  week,  and  for  some 
time  afterwards  had  to  live  upon  soft  food.  There  was 
profuse  salivation,  and  for  a  month  the  wound  discharged 
pus.  The  mouth  in  the  situation  of  the  wound  remained 
red  and  swollen  for  two  years,  but  there  was  no  suppura- 
tion after  the  first  month.  Two  years  later,  a  portion  of 
pipe  stem  was  noticed  projecting  a  quarter  of  an  inch 
beyond  the  site  of  the  old  wound.  It  was  loose,  and  was 
easily  removed  with  a  pair  of  forceps. 


27O      THE    SURGICAL    DISEASES    OF    CHILDREN 

FOREIGN  BODIES  IN  THE  (ESOPHAGUS. 

Children  who  have  swallowed  various  foreign  bodies  are 
constantly  brought  to  the  surgeon.  In  the  majority  of 
cases,  the  bodies  pass  smoothly  through  the  oesophagus 
into  the  stomach,  and  are  eventually  cast  out  into  the 
draught,  though  it  sometimes  happens  that  they  are  never 
seen  again. 

In  every  case,  however,  a  child  who  is  reported  to  have 
swallowed  a  foreign  body  should  be  examined  with  the 
finger,  and  even  if  nothing  can  be  felt,  a  probang  should 
be  passed  as  soon  as  possible,  partly  for  the  satisfaction 
of  the  surgeon,  but  chiefly  to  relieve  the  anxiety  of  the 
friends.  The  usual  treatment  when  the  body  has  passed 
into  the  stomach,  consists  in  giving  porridge  and  hasty- 
pudding  for  a  day  or  two,  and  then  a  purge  of  castor 
oil.  The  foreign  body  sometimes  becomes  impacted  in  the 
oesophagus,  and  if  it  is  smooth,  like  a  coin  or  a  marble, 
it  may  give  rise  at  first  to  very  few  symptoms,  though 
sooner  or  later  the  mucous  membrane  swells,  the  muscular 
coat  yields,  and  the  impacted  body  becomes  enclosed  in  a 
pouch,  from  which  it  is  impossible  to  remove  it  without 
having  resort  to  cesophagotomy.  Suppuration  often  occurs 
in  such  cases,  the  temperature  rises,  and  the  child  dies 
with  pneumonia.  The  early  recognition  of  a  body  im- 
pacted in  the  oesophagus  is  therefore  of  the  greatest 
importance. 

The  diagnosis  is  often  difficult  when  the  body  is  smooth, 
but  it  becomes  proportionately  easier  as  the  body  is  more 
irregular  or  ragged  in  outline.  A  halfpenny  is  just  large 
enough  to  be  firmly  grasped  by  the  oesophageal  wall  if  it 
lies  vertically.  It  is  often  situated  flat  along  the  posterior 
wall  of  the  larynx,  and  it  readily  eludes  recognition  by 
lying  just  beyond  the  reach  of  the  finger.     The  impaction 


FOREIGN    BODIES    IN    THE    OESOPHAGUS      27  I 

of  foreign  bodies  in  the  lower  part  of  the  oesophagus  is 
much  less  common,  though  I  have  seen  a  marble  lying  an 
inch  above  the  cardiac  orifice  of  the  stomach  cause  death 
by  ulceration  in  a  girl  of  four  years  old. 

Treatment.— A  bimanual  examination  of  the  gullet 
must  be  made  in  all  doubtful  cases  of  impaction,  and  Dr. 
Polikier  of  Warsaw  reports  two  cases  in  which  he  has 
been  able  to  remove  such  bodies  in  children  by  external 
manipulation  of  the  oesophagus.  Emetics  are  never  ser- 
viceable in  causing  a  child  to  eject  an  impacted  foreign 
body,  for  the  straining  which  they  produce  is  likely  to 
lead  to  rupture  of  the  softened  tissues.  Endeavours  must 
at  once  be  made,  and  with  discretion,  to  dislodge  the  body 
by  means  of  a  probang  or  other  instrument.  Forceps  have 
never  proved  themselves  of  any  use  in  my  hands. 

(Esophagotomy  must  be  employed  when  these  measures 
are  unsuccessful ;  and  it  should  be  performed  at  once,  for 
the  surgeon  should  remember  that  the  operation  is  not  a 
particularly  dangerous  one  if  it  be  done  early,  and  before 
the  temperature  has  begun  to  rise ;  while  the  child  is 
almost  certain  to  die  if  the  body  be  left  in  position.  The 
average  mortality  after  opening  the  oesophagus  to  remove 
an  impacted  body  is  given  by  Fischer  as  33  per  cent. ; 
but  this,  of  course,  includes  many  cases  in  which  the 
operation  was  performed  as  a  last  resource.  The  operation 
is  performed  in  exactly  the  same  manner  as  in  adults,  upon 
the  left  side,  and  through  an  incision  corresponding  to  that 
used  for  tying  the  upper  part  of  the  common  carotid.  Care 
must  be  taken  not  to  injure  the  recurrent  laryngeal  nerve 
where  it  lies  between  the  oesophagus  and  trachea,  and  not 
to  wound  the  inferior  thyroid  artery  until  preparations 
have  been  made  to  secure  it.  The  oesophagus  should  be 
made  to  project  into  the  wound  by  passing  a  sound, 
catheter,  or  oesophageal  forceps,  through  the  mouth.     It 


272      THE    SURGICAL    DISEASES    OF    CHILDREN 

should  be  opened  with  a  scalpel,  and  the  opening  must  be 
enlarged  by  a  pair  of  blunt-pointed  scissors.  The  foreign 
body  must  be  gently  removed  with  sequestrum  forceps, 
and  the  wall  of  the  oesophagus  should  be  sewn  up  with 
Lembert's  sutures  if  it  is  healthy  and  not  softened  by 
prolonged  inflammation.  The  patient  must  be  fed  by  the 
rectum  for  a  few  days,  but  as  soon  as  possible  a  soft 
catheter  should  be  passed  into  the  stomach  at  meal-times. 
Some  surgeons  prefer  to  introduce  the  tube  through  the 
nose,  and  leave  it  in  position  for  several  days,  only  taking 
it  out  now  and  again  to  clean  it.  The  tube  causes  less 
faucial  irritation  when  it  is  passed  through  the  nose  than 
when  it  is  introduced  through  the  mouth. 

STRICTURE   OF   THE   (ESOPHAGUS. 

Non-malignant  strictures  may  occur  at  either  end  of  the 
oesophagus  in  children :  at  the  upper  end,  as  a  result  of 
incomplete  processes  of  development,  at  the  point  where 
the  stomadseum  joins  the  mesenteron,  or  more  frequently 
from  cicatricial  stenosis  caused  by  swallowing  corrosive 
substances,  or  by  scalds.  A  very  rare  form  of  stricture 
has  been  observed  at  the  lower  end  of  the  oesophagus,  due 
to  simple  hypertrophy  of  the  muscular  coat  of  the  pylorus. 


CHAPTER  XIII 

SURGICAL  DISEASES   OF   THE   TONSILS, 
PHARYNX,   AND   NOSE 

CHRONIC  ENLARGEMENT   OF   THE   TONSILS. 

Nothing  in  the  whole  range  of  children's  disease  more 
often  presents  itself  for  treatment  than  chronic  enlarge- 
ment of  the  tonsils.  The  enlargement  is  most  frequent 
between  the  ages  of  five  and  of  twenty  years  of  age, 
though  it  is  not  uncommon  to  see  it  in  much  younger 
children.  It  is  by  no  means  always  associated  with 
adenoid  vegetations.  The  cause  of  the  enlargement  is 
unknown,  but  it  is  often  associated  with  that  debilitated 
condition  which  may  pass  with  the  assistance  of  a  suit- 
able infective  agent  into  tubercle. 

Varieties. — The  enlargement  assumes  two  distinct 
forms,  the  one  truly  hypertrophic,  in  which  the  organ  is 
increased  in  size  and  studded  with  crypts.  In  these  cases 
the  lymphoid  tissue  is  increased  in  quantity,  and  the  vas- 
cular supply  is  correspondingly  large,  but  there  is  only  a 
slight  increase  in  the  connective  tissue  stroma  of  the 
gland.  In  the  second  form  there  is  an  overgrowth  of  the 
connective  tissue  elements,  without  a  corresponding  in- 
crease in  the  lymphoid  tissue.  In  these  cases  the  crypts 
are  absent,  the  blood  supply  is  diminished,  and  the  tonsil 
often  appears  pale.  The  hypertrophied  tonsils  either  in- 
crease in  their  lateral  diameter,  and  project  towards  the 

273  T 


274      THE    SURGICAL    DISEASES    OF    CHILDREN 

uvula,  or  they  grow  antero-posteriorly,  when  they  lie  fiat 
in  the  fauces  and  may  yet  extend  for  some  distance  down 
the  pharynx.  Inflammatory  adhesions  sometimes  bind 
down  the  tonsil  to  one  or  both  pillars  of  the  fauces.  Both 
tonsils  are  usually  enlarged,  but  it  often  happens  that  only 
one  is  affected. 

Symptoms. — The  symptoms  are  not  easily  mistaken 
in  an  advanced  stage.  The  patient  is  slightly  deaf, 
though  the  deafness  is  more  frequent  when  adenoids  are 
present ;  the  character  of  his  voice  is  so  altered  as  to  lead 
to  the  idea  that  he  is  talking  with  his  mouth  full,  and 
there  is  an  absence  of  nasal  tone.  The  breath  is  foul, 
respiration  and  even  deglutition  may  be  impaired,  and 
there  may  be  many  of  the  sequelae  associated  with 
adenoids. 

The  deficient  oxygen  supply  leads  to  anaemia,  and  pre- 
disposes the  child  to  catch  any  infectious  disease,  at  the 
same  time  rendering  it  less  able  to  withstand  the  disease, 
so  that  it  usually  experiences  the  full  force  of  an  epidemic. 
A  good  instance  of  this  recently  came  under  my  notice. 
Diphtheria  attacked  a  family  of  four  children  ;  the  two 
eldest,  who  were  girls,  had  enlarged  tonsils,  and  were  re- 
peatedly subject  to  tonsillitis.  The  third  child,  a  boy,  was 
healthy,  and  the  fourth  was  a  baby  in  arms.  The  two 
eldest  children  died,  whilst  the  boy  and  the  baby  escaped. 
There  is  very  great  probability  that  if  the  enlarged  tonsils 
in  these  cases  had  been  removed  before  the  attack,  the 
two  lives  would  have  been  spared.  The  deficient  supply 
of  oxygen  is  often  a  cause  of  nightmare  in  children ;  to 
be  distinguished,  as  Dr.  Bosworth  very  shrewdly  remarks, 
by  the  fact  that  the  nightmare  of  indigestion  only  occurs 
once  in  a  night,  whilst  that  due  to  want  of  air  may  be 
repeated  many  times. 

The  signs  are  equally  obvious.    The  mouth  is  kept  open, 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  275 


as  nasal  respiration  is  often  impossible.  This  leads,  on  the 
one  hand,  to  drying  of  the  fances  and  a  reflex  cough  ;  and, 
ou  the  other,  to  the  stupid  expression  which  is  so  well 
reproduced  in  many  of  Du  Maimer's  pictures  of  society 
life.  Impairment  of  hearing  is  also  a  very  frequent  con- 
comitant of  chronic  hypertrophy  of  the 
tonsils. 

Diagnosis. — Inspection  of  the  fauces 
will  at  once  confirm  the  diagnosis. 
This  is  best  effected  by  pressing  the 
tongue  down  firmly  but  slowly,  and  at 
the  same  time  drawing  it  forward  until 
a  good  view  of  the  tonsils  is  obtained. 
This  is  done  with  a  spatula,  and  the 
double  movement  necessary  is  easily 
acquired  after  a  little  practice.  The 
only  error  into  which  it  is  possible  to 
fall  is  to  mistake  an  acute  inflammation, 
or  a  new  growth,  for  chronic  enlargement 
of  the  tonsil. 

Treatment.  Palliative. — It  is  not 
necessary  to  perform  tonsillotomy  in 
every  case  of  enlarged  tonsils,  but  it  is 
necessary  to  do  so  where  they  give  rise 
to  obvious  signs  of  interference  with 
the  supply  of  air  to  the  lungs,  and 
when  they  are  liable  to  recurrent  at- 
tacks of  inflammation.  Only  in  very 
rare  cases  do  they  require  removal  a 
second  time.  Astringents  should  be 
employed  where  there  is  reason  to  sus- 
pect that  the  enlargement  is  due  to  chronic  irritation, 
rather  than  to  true  hypertrophy.  The  astringents  I  have 
been  accustomed  to  use  are  glycerin  of  tannic  acid,  a  solu- 


3 


o 


© 

CO 


276      THE    SURGICAL    DISEASES    OF    CHILDREN 

tion  of  nitrate  of  silver,  four  grains  to  the  ounce,  or  a 
solution  of  sulphate  of  zinc,  containing  a  drachm  to  the 
ounce.  These  solutions  are  painted  over  the  tonsil  night 
and  morning  by  means  of  a  camel-hair  brush  in  a  handle. 

Operative. — The  proper  treatment  for  most  cases  of 
chronic  tonsillar  enlargement  is  removal.  This  was  re- 
cognised by  Celsus,  who  says  (Medicince  lib.  Septimus, 
xii.  2) :  "  Tonsillas  an  tern,  quse  post  inflammationes 
induruerunt,  dvriaSes  autem  a  Grrsecis  appellantur,  cum  sub 
levi  tunica  sint,  oportet  digito  circumradere  et  evellere  :  si 
ne  sic  quidem  resolvuntur,  hamulo  excipere,  et  scalpello 
excidere ;  turn  ulcus  aceto  eluere,  et  illinere  vulnus  medi- 
camento,  quo  sanguis  supprimitur."  This  method  of 
removing  the  tonsils  with  a  bistoury,  after  it  has  been 
seized  and  drawn  forwards  in  a  vulsellum,  is  still  used 
by  many  practitioners,  though  it  has  lately  been  super- 
seded by  a  tonsillotome.  The  particular  form  of  tonsil- 
lotome  employed  is  unimportant,  for  each  surgeon  uses 
the  one  with  which  he  is  most  familiar.  Heister's  instru- 
ment, as  modified  by  Matthieu  (fig.  30),  is  very  useful ; 
but  care  should  be  taken  to  see  that  the  bevelled  and 
not  the  flat  side  of  the  cutting  blade  is  next  to  the  fork. 
Many  surgeons,  however,  prefer  a  simpler  instrument ; 
but,  whatever  method  is  employed,  as  large  a  piece  of  the 
tonsil  as  possible  should  be  removed. 

It  has  long  been  an  accredited  piece  of  folk-lore  that 
there  is  a  relationship  between  the  tonsils  and  the  genera- 
tive organs,  and  that  if  the  tonsils  be  removed  in  children 
there  will  be  a  diminution  or  loss  of  the  reproductive 
power  after  puberty.  This  hare  has  recently  been  started 
afresh  in  a  half -joking  way  in  America  by  Dr.  Penrose  (see 
the  Medical  Gazette,  N.Y.,  1881,  viii.  p.  92),  and  the  fable 
has  thus  acquired  a  fresh  lease  of  life,  for  I  have  several 
times  been  asked  during  the  last  few  years  whether  there 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  277 

was  any  truth  in  it.  It  is  obviously  false,  and  the  con- 
verse is  the  more  likely  to  prove  true,  owing  to  the 
impaired  vitality  produced  by  impeded  respiration. 

The  mouth  in  unhealthy  children  should  be  washed  out 
before  the  operation  with  1  per  cent,  solution  of  carbolic 
acid,  night  and  morning,  for  a  few  days ;  and  if  there  is  a 
purulent  nasal  catarrh,  aristol  may  be  insufflated  into  the 
nasal  fossse  three  times  a  day.  Dr.  Caille  has  recently 
pointed  out  that  it  is  well  not  to  remove  tonsils,  if  the 
operation  can  conveniently  be  postponed,  during  epidemics 
of  diphtheria,  for  tonsillotomy  in  such  cases  is  sometimes 
followed  by  an  attack  of  diphtheria,  due,  no  doubt,  to  the 
fact  that  bacilli  which  have  been  lying  quiescent  in  the 
naso-pharynx  thus  gain  access  to  an  open  wound. 

The  patient  is  placed  upright  upon  a  stool  at  the  time 
of  the  operation,  and  the  surgeon  sits  exactly  facing  him, 
and  upon  a  slightly  higher  level,  with  a  spatula  in  his 
left  hand  and  the  tonsillotome  in  his  right  ;  the  nurse  or 
assistant  stands  behind  the  patient,  and  steadies  his  head, 
whilst  with  her  finger  and  thumb  she  presses  on  either 
side  of  the  nesk,  just  behind  and  below  the  angle  of  the 
jaw,  to  make  the  tonsil  somewhat  more  projecting.  No 
gag  is  required.  The  tonsillotome  is  easily  introduced  if 
the  child's  confidence  has  been  gained ;  and  it  is  much 
more  satisfactory  to  do  the  operation  in  this  way  than  to 
have  recourse  to  force  or  to  partial  anaesthesia,  though 
such  means  are  sometimes  unavoidable.  The  tonsillotome 
must  be  applied  from  below  upwards,  so  as  to  include  any 
portion  of  the  gland  which  may  be  hanging  down  into  the 
pharynx,  and  both  tonsils  should  be  removed  at  the  same 
sitting.  The  pain  is  so  trivial  that  I  do  not  consider  it 
necessary  even  to  paint  on  cocain,  since  it  is  as  trouble- 
some to  do  so  in  a  child  as  to  remove  the  tonsils  them- 
selves.   There  may  be  rather  sharp  bleeding,  and  to  prevent 


278      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  blood  passing  down  the  pharynx,  the  head  is  pressed 
forwards  as  soon  as  the  tonsillotome  with  the  excised  piece 
of  tonsil  has  been  withdrawn  from  the  mouth. 

Tonsils  may  also  be  removed  by  the  snare,  by  the 
galvano-cautery,  and  by  the  application  of  caustics,  all 
methods  which  are  less  applicable  to  children  than  to 
adults.  Broad,  flat  tonsils  always  require  to  be  removed 
with  scissors  and  forceps,  for  no  form  of  guillotine  will 
seize  them.  It  sometimes  happens  that  the  tonsils  are  so 
soft  that  the  guillotine  cannot  be  used,  for  it  merely  tears 
through  the  tissue ;  or  the  glandular  substance  may  be  so 
adherent  to  the  pillars  of  the  fauces  that  it  cannot  be  re- 
moved in  the  ordinary  manner.  M.  Ruault  has  recently 
suggested  that  the  tonsil  in  such  cases  should  be  removed 
piecemeal  with  a  pair  of  punch  forceps,  liniment  of  iodine 
being  afterwards  applied  to  the  bleeding  surface.  I  have 
never  had  occasion  to  resort  to  such  a  method. 

After-Treatment.  —  The  after-treatment  consists  in 
giving  the  child  bread  and  milk  for  forty-eight  hours  until 
the  wound  has  healed,  and,  if  necessary,  applying  a  cold 
compress  to  the  neck. 

Dangers  attending  the  Operation. — The  operation 
in  the  large  majority  of  cases  is  a  trivial  one,  and  if  the 
pillars  of  the  fauces  are  not  injured  the  bleeding  very  soon 
ceases.  It  occasionally  happens,  however,  that  dangerous 
haemorrhage  25  occurs  either  at  the  time  of  the  operation,  or 
some  hours  or  days  afterwards,  and  this  possibility  should 
always  be  borne  in  mind.  The  proper  treatment  for  these 
cases  is  direct  digital  pressure  upon  the  bleeding  point,  for 
it  appears  that  styptics  are  usually  without  avail,  and 
even  ligature  of  the  external  and  of  the  common  carotid 
arteries  has  not  arrested  it.  Mr.  de  Santi  suggests  that 
the  method  recommended  by  Mr.  Treves  for  the  arrest  of 
bleeding   in   the   neck  might  prove  serviceable  in  these 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  279 

cases.  It  consists  in  exposing  the  external  carotid  artery 
in  the  usual  manner,  and  occluding  it  by  tying  a  thick 
catgut  ligature  loosely  round  it.  The  circulation  in  the 
artery  is  arrested  when  the  ligature  is  pulled  upon,  and  is 
restored  as  soon  as  the  traction  is  relaxed.  The  bleeding 
is  generally  arterial,  and  seems  to  come  from  a  branch  of 
the  tonsillar  artery ;  but  it  is  sometimes  a  general  oozing, 
which  only  ceases  when  the  loss  of  blood  has  provided  a 
natural  styptic.  If  the  bleeding  be  slight  but  trouble- 
some, Sir  Morell  Mackenzie's  formula  may  be  used.  It  is, 
Acid,  gallici  Jy  ii. ;  acid,  tannici  3  vi. ;  aq.  3  i.  Misce.  Sip 
and  swallow  half  a  teaspoonful  at  frequent  intervals. 

ADENOID  VEGETATIONS  25 

(Syn.  Post-Nasal  Growths,  Hypertrophy  of  the 
Pharyngeal  Tonsil). 

Adenoids  are  nodules  of  lymphoid  tissue  grouped  into 
masses,  and  covered  with  ciliated  epithelium.  They  are 
formed  by  a  simple  overgrowth  of  the  lymphoid  tissue 
normally  found  in  the  vault  of  the  pharynx,  and  are  fre- 
quently associated  with  chronic  enlargement  of  the  tonsils. 
These  overgrowths  are  equally  common  in  boys  and  in 
girls.  They  may  be  found  at  birth,  and  they  sometimes 
persist  into  early  adult  life  ;  but  they  are  more  frequently 
seen  before  than  after  ten  years  of  age.  Racial  idiosyn- 
cracies  are  said  to  play  a  great  part  in  their  production. 

They  were  first  recognised  by  Czermak  in  1860  ;  but 
Wilhelm  Meyer,  of  Copenhagen,  was  the  first  to  attach 
importance  to  them  as  factors  in  the  causation  of  disease. 

./Etiology.— The  growths  occur  in  those  who  are  pre- 
disposed to  colds,  perhaps  in  tuberculous  subjects,  and  in 
those  whose  nasal  passages  are  narrowed  from  any  cause, 
either  congenital  or  acquired.     Such  narrowing  leads  to 


280      THE    SURGICAL    DISEASES    OF    CHILDREN 

chronic  hyperemia,  and  in  course  of  time  to  overgrowth 
of  the  tissues.  Damp  and  cold  climates  are  also  pre- 
disposing causes,  whilst  a  syphilitic  taint  produces  a 
somewhat  similar  overgrowth  of  pharyngeal  lymphoid 
tissue,  which  can  only  be  successfully  treated  by  the  use 
of  mercury. 

The  exciting  causes  of  adenoid  vegetations  are  those 
leading  to  chronic  hypersemia  of  the  parts,  such  as 
repeated  and  neglected  nasal  catarrh,  diphtheria,  whooping 
cough,  the  exanthemata,  especially  measles  and  scarlet 
fever. 

Symptoms. — The  symptoms  are  snoring,  a  mucous 
discharge,  altered  speech,  and,  in  time,  a  peculiar  and 
characteristic  aspect.  The  snoring  is  an  early  but  not 
necessarily  a  constant  symptom.  It  occurs,  as  Mr.  C.  A. 
Parker  points  out,  because,  during  sleep,  air  enters  the 
lungs  through  the  nasal  passages  rather  than  through  the 
mouth,  as  is  usual  when  the  patient  is  awake.  He  further 
shows  that,  although  86  per  cent,  of  the  cases  of  nasal  ob- 
struction sleep  with  their  mouths  open,  in  82  per  cent,  the 
respiration  is  entirely  nasal,  and  in  16  per  cent,  it  is  partly 
nasal  and  partly  buccal.  Bad  dreams,  night  terrors,  and 
sometimes  slight  delirium  may  be  the  result  of  this  deficient 
aeration  of  the  blood,  whilst  its  remote  effects  are  said  to  be 
anaemia,  stunted  growth,  impaired  cerebral  development, 
deformities  of  the  chest,  asthma,  laryngismus  stridulus, 
and  even  epilepsy. 

A  muco-purulent  discharge  fills  the  nostrils  and  runs 
down  the  pharynx.  The  voice  is  characteristically  altered, 
and  the  alteration  is  observed  earlier  in  singing  than  in 
speaking.  It  is  thick,  and  there  is  difficulty  in  pronounc- 
ing many  of  the  consonants,  thus  B  replaces  P,  D  replaces 
T,  and  B  is  used  for  M ;  a  change  due  in  part  to  the  en- 
feeblement  of  the  soft  palate,  and  in  part  to  the  nasal 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  28  I 

obstruction,  which  no  longer  allows  the  vault  of  the 
pharynx  to  act  as  a  sounding-board.  The  facial  expression 
is  characteristic  in  the  later  stages,  for  the  patient  has  a 
dull  and  heavy  look,  with  a  sallow  complexion.  His  lips 
are  prominent,  thick,  and  without  expression,  and  his 
mouth  is  open.  The  nostrils  are  narrow,  and  each  ala  of 
the  nose  is  indented  at  the  junction  of  the  superior  and 
inferior  lateral  cartilages,  whilst  the  bridge  is  broad,  and 
is  often  crossed  by  a  congested  vein.  The  broad  bridge 
and  the  narrow  alas  make  the  eyes  appear  unduly  far 
apart.  The  patient  is  often  hard  of  hearing,  and,  in 
advanced  cases,  the  arch  of  the  palate  loses  its  rounded 
form  and  becomes  more  pointed. 

Chronic  hypertrophy  of  the  tonsils  is  usually  associated 
with  adenoid  vegetations  ;  but  it  often  happens  that  the 
growths  occur  independently  of  chronic  tonsillitis.  The 
pillars  of  the  fauces,  the  soft  palate,  and  the  uvula  are 
congested.  The  parts  look  dusky  and  flabby,  and  there  is 
often  impaired  movement  of  the  palate.  The  back  of  the 
pharynx  is  covered  with  muco-pus,  and  it  is  studded  with 
large  and  pale  granulations,  increasing  in  size  as  they 
approach  the  naso-pharynx.  The  results  of  the  obstruction 
act  in  two  directions.  In  the  early  stages,  as  Dr.  Scanes 
Spicer  has  shown,  the  presence  of  the  adenoids  leads  to 
chronic  congestion  and  hypertrophy  of  the  post-nasal 
mucous  membrane,  with  dilatation  of  the  vein  running 
across  the  roof  of  the  nose ;  whilst  in  the  later  stages,  the 
obstruction  may  be  so  complete  as  to  lead  to  pharyngitis 
sicca,  for  the  air  only  passes  through  the  inferior  meatus 
of  the  nose,  and  so  is  insufficiently  moistened. 

Diagnosis. — The  diagnosis  is  readily  made  in  all  stages 
of  the  disease  by  digital  examination  of  the  naso-pharynx. 
The  surgeon  should  stand  behind  and  on  the  right  side  of 
the  patient,  who  sits  in  a  chair.     He  wraps  a  piece  of  lint 


282      THE    SURGICAL    DISEASES    OF    CHILDREN 

round  his  left  forefinger,  or  protects  it  with  a  shield  of 
horn  or  celluloid,  and  employs  it  as  a  gag,  whilst  he  intro- 
duces his  right  index  into  the  mouth,  passing  it  beyond 
the  soft  palate,  and  then  bending  it  upwards  to  explore 
the  naso-pharynx.  The  exploration  must  be  done  methodi- 
cally, and  the  growths  are  detected  as  masses  of  soft  and 
velvety  tissue,  in  the  form  of  ridges,  cushions  or  lobules  at 
the  upper  part  and  sides  of  the  posterior  nares.  A  firm 
pad  of  thickened  tissue,  situated  in  the  pharyngeal  vault, 
a  little  to  one  side  of  the  middle  line,  can  often  be  felt 
when  the  growths  have  disappeared  spontaneously.  Pos- 
terior rhinoscopy,  in  experienced  hands,  gives  good  results, 
and  it  may  readily  be  applied  to  tractable  children.  It 
is  often  a  useful  supplement  to  digital  examination,  unless 
the  tonsils  are  enlarged,  when  it  is  a  very  difficult  method 
to  use.  Bosworth's  mode  of  detecting  nasal  obstruction 
may  be  used  in  doubtful  cases.  It  consists  in  spraying 
sweet  oil  into  one  nostril.  The  heavy  spray  returns  with 
almost  equal  force  through  the  other  nostril,  if  the  nasal 
passages  and  naso-pharynx  are  quite  clear,  but  not  other- 
wise. 

Differential  Diagnosis.  —  Adenoids  are  to  be  dis- 
tinguished from  polypus  of  the  nose,  which  is  very  rare  in 
children  ;  from  fibrous  growths,  which  are  harder  than 
adenoid  vegetations  ;  and  from  enlargement  of  the  posterior 
ends  of  the  inferior  turbinated  bones,  which  are  easily 
recognised  by  digital  examination.  Retro  -  pharyngeal 
abscess  is  so  painful,  and  runs  such  a  rapid  course,  that  it 
is  not  likely  to  be  mistaken  for  post-nasal  growths ;  whilst 
a  retro-pharyngeal  sarcoma  causes  more  bulging  of  the 
surrounding  parts,  especially  of  the  soft  palate,  and  leads 
to  greater  enlargement  of  the  cervical  glands. 

Sequelae. — Adenoids  are  a  frequent  cause  of  deafness, 
and  of   inflammation  of  the  middle  ear.      They  produce 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  283 

hyperemia  of  the  Eustachian  tubes,  and  of  the  tympanic 
cavities,  which  leads  to  thickening  of  the  mucous  mem- 
brane lining  the  cavities  of  the  ear,  or  to  an  increased 
activity  of  the  glands,  terminating  in  a  suppurative  in- 
flammation, with  subsequent  perforation  of  the  tympanic 
membrane.  The  frequency  of  ear-trouble  in  these  cases  is 
explained  in  many  ways,  but  every  one  agrees  that  it  is 
associated  with  diminished  air  tension  in  the  middle  ear. 

Treatment.  —  The   increased    liability    to    disease    to 
which  children  with  adenoids  are  liable,  renders  it  advis- 


Fig.  31.— Two  forms  of  Gottstein's  Curette,  used  in  removing  adenoids. 


able  to  remove  the  growths  as  soon  as  they  cause  the 
patient  to  breathe  through  his  mouth.  They  do  not  recur 
after  complete  removal ;  but  it  is  not  sufficient  to  scarify 
them,  or  merely  to  crush  them.  The  child  should  be  put 
under  chloroform,  so  that  the  operation  may  be  performed 
with  deliberation,  and  it  is  of  extreme  importance  that 
the  anaesthesia  should  not  be  too  deep.  The  patient 
should  be  able  to  cough  refiexly  throughout  the  operation, 
as  there  is  then  less  risk  of  suffocation  from  blood  entering 
the  larynx.  Every  operator  has  his  favourite  position  and 
method  of  removal.  I  am  accustomed  to  have  the  head 
hanging  over  the  end  of  the  table,  so  that  the  blood  does 
not  run  down  the  throat,  although  in  this  position  there 


284      THE    SURGICAL    DISEASES    OF    CHILDREN 

is  increased  venous  engorgement  of  the  head  and  neck ; 
but  many  surgeons  prefer  to  have  the  patient  lying  upon 
his  side,  with  his  head  level  with  the  rest  of  his  body. 
A  gag  being  placed  in  the  mouth,  the  growths  are  syste- 
matically removed,  through  the  mouth  and  naso-pharynx, 
with  some  modification  of  Loewenberg's  forceps,  with 
Meyer's  ring  knife,  Gottstein's  curette  (fig.  31),  with  Sir 
William  Dalby's  artificial  finger-nail  (fig.  32),  or,  less  pre- 
ferably, with  the  finger-nail  itself ;  and  it  is  often  neces- 
sary to  use  a  combination  of  these  instruments  before  the 
growths  can  be  completely  extirpated.  Many  operators, 
however,  choose  to  remove  the  growths  with  a  sharp  spoon 


Fig.  32.— Dalby's  Artificial  Nail,  employed  in  removing  adenoids. 


passed  through  the  nares,  and  guided  by  a  finger  in  the 
mouth.  The  nasal  cavity  is  repeatedly  swabbed  out  dur- 
ing the  operation  with  wet  absorbent  wool.  The  bleeding 
is  very  free  ;  but  it  usually  stops  as  soon  as  the  gag  is 
removed  and  the  mouth  is  closed.  The  tonsils  should 
be  removed  if  it  is  necessary,  and  whilst  the  patient 
is  still  unconscious. 

The  operation  is  not  quite  free  from  risk,  as  it  some- 
times causes  a  sharp  attack  of  suppurative  inflammation 
in  the  middle  ear  two  or  three  days  afterwards.  This  may 
be  due  to  the  entrance  of  blood  through  the  Eustachian 
tubes,  and  it  is  especially  likely  to  occur  in  those  cases 
of  sub-acute  otitis  media  which  are  characterised  by 
thickening  and  retraction  of  the  tympanic  membrane,  or 
by  its  perforation.     Pneumonia  occasionally  results  from 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  2S5 

the  passage  of  blood  into  the  lungs ;  but  this  should  not 
occur  if  proper  care  be  taken  at  the  time  of  the  operation. 

After-Treatment. — Little  or  no  after-treatment  is  re- 
quired, except  to  keep  the  patient  in  bed  for  a  day  or  two 
in  a  warm  room,  and  to  give  soft  food  until  the  bruised  parts 
have  recovered.  A  gargle  or  an  alkaline  spray,  similar  to 
that  used  for  diphtheria  (chap,  xvii.),  may  also  be  employed 
for  a  week,  and  the  Eustachian  tubes  should  be  inflated 
regularly,  if  the  deafness  remain  more  than  a  fortnight  or 
three  weeks  after  the  adenoids  have  been  removed. 

The  beneficial  effects  of  the  operation  are  often  very 
striking.  The  patients  rapidly  increase  in  height,  weight, 
and  chest  girth,  and  at  the  same  time  lose  the  facial  ex- 
pression which  had  previously  characterised  them. 

ACUTE  TUBERCULOUS  INFLAMMATION   OF 
THE  PHARYNX. 

The  pharynx  in  children  is  occasionally  the  seat  of  an 
acute  tuberculous  ulceration.  It  may  be  the  result  of  an 
extension  from  the  soft  palate  and  uvula,  but  is  usually  se- 
condary to  disease  of  the  lower  part  of  the  respiratory  tract. 
Drs.  Abercrombie  and  Gay,28  who  have  paid  special  atten- 
tion to  the  condition  in  England,  say  that  the  first  sign  is 
the  appearance  of  small  discrete  papules  on  the  soft  palate, 
pillars  of  the  fauces,  and  still  more  rarely,  on  the  posterior 
wall  of  the  pharynx.  These  papules  are  tuberculous  ;  they 
caseate  and  then  ulcerate,  implicating  the  surrounding 
parts,  and  causing  great  destruction  of  the  tissues.  The 
mucous  membrane  is  swollen,  and  is  covered  with  a  viscid, 
whitish  secretion,  which  may  be  mistaken  for  a  diphtheri- 
tic membrane ;  but  it  is  less  organised  and  more  friable. 
The  retro-pharyngeal  and  cervical  lymphatic  glands  become 
enlarged,  and  the  latter  may  suppurate,  or  the  glands  may 


286      THE    SURGICAL    DISEASES    OF    CHILDREN 

subside  entirely  before  the  termination  of  the  case.     The 
chronic  form  of  this  condition  is  lupus  (p.  57). 

Symptoms. — The  first  symptom  is  pain,  with  more  or 
less  dyspnoea ;  a  nasal  quality  of  the  voice,  from  impaired 
action  of  the  palatal  muscles  ;  and  pain  in  the  ear  from  im- 
plication of  the  Eustachian  tube.  Deafness  occasionally 
occurs. 

Diagnosis. — The  ulceration  is  not  always  easy  to  see, 
on  account  of  the  viscid  secretion  which  covers  the  fauces. 
Follicular  tonsillitis,  diphtheria,  and  the  mucous  patches 
of  inherited  syphilis  have  to  be  distinguished  from  this 
condition  of  acute  tuberculous  ulceration  of  the  fauces. 

Prognosis. — The  prognosis  is  extremely  bad ;  nearly  all 
the  cases  have  terminated  fatally,  for  the  condition  appears 
to  be  a  part  of  a  general  tuberculosis.  The  immediate 
cause  of  death  is  dysphagia. 

Treatment.  —  The  treatment  is  unsatisfactory,  for 
little  can  be  done  except  to  relieve  the  pain  by  insufflations 
of  morphia,  or  by  cocain  spray. 

NASO-PHAEYNGEAL  TUMOURS. 

Pathology.  —  Tumours  of  the  naso-pharynx  are  not 
uncommon  in  children.  They  are  either  simple  fibromata, 
the  fibrous  tissue  sometimes  having  a  nsevoid  character, 
so  that  the  tumour  is  a  fibro-angioma ;  or  they  are  fibro- 
sarcomata ;  or,  more  rarely,  they  are  atypical,  and  contain 
cartilage  cells.  The  tumours,  in  either  case,  are  generally 
single,  and  have  a  large  base  of  attachment.  They  usually 
grow  from  the  fibrous  tissue  covering  the  basilar  process 
of  the  occipital  bone  ;  but  many  cases  are  known  to  have 
originated  in  the  pterygo-maxillary  fossa.  They  grow 
irregularly,  and  often  acquire  secondary  attachments. 
Nothing  is  known  of  their  cause.  They  are  found  almost 
exclusively  in  boys  and  in  young  adults.     They  are  rare 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  287 

in  children  under  ten,  and  are  most  common  between  the 
ages  of  eleven  and  twenty-five. 

Symptoms. — The  earlier  symptoms  marking  their 
growth  are  so  slight  that  the  patient  is  not  brought  for 
advice  until  the  growth  has  attained  to  a  considerable 
size.  The  slight  epistaxis,  the  constant  nasal  secretion, 
the  chronic  headache,  and  the  hardness  of  hearing  which 
mark  the  early  stages  of  growth,  are  usually  attributed 
to  chronic  cold  in  the  head,  or  to  adenoids.  It  is  not  until 
the  symptoms  increase  that  the  patient  is  brought  for 
advice,  and  then,  a  digital  examination  of  the  back  of  the 
pharynx  readily  enables  the  tumour  to  be  felt.  This 
examination  must  be  conducted  with  the  greatest  gentle- 
ness, for  it  sometimes  leads  to  a  sharp  haemorrhage. 

Prognosis. — The  younger  the  patient  the  more  quickly 
the  tumour  grows,  and  if  it  be  left  alone  the  most  disas- 
trous results  follow.  The  nasal  fossae  become  dilated,  and 
the  growth  invades  the  surrounding  parts,  growing  up- 
wards into  the  orbit  and  brain,  laterally  into  the  zygomatic 
and  temporal  fossae,  downwards  into  the  mouth,  and 
forwards  into  the  cheek,  producing  the  most  frightful 
deformity.  Death  may  take  place  within  a  few  months  of 
the  first  symptoms,  or  it  may  be  postponed  for  a  year  or 
two. 

Diagnosis. — A  naso-pharyngeal  fibroma  or  sarcoma  is 
not  likely  to  be  mistaken  for  anything  else.  It  is  recorded, 
however,  that  a  retro-pharyngeal  abscess  was  mistaken 
for  such  a  growth  in  one  case ;  whilst  in  others,  an  ence- 
phalocele  projecting  into  the  pharynx  led  to  a  similar 
error  in  diagnosis. 

Treatment. — The  treatment  of  the  smallest  innocent 
tumours  consists  in  twisting  them  off  with  forceps,  intro- 
duced either  through  the  mouth  or  nostril.  The  larger 
polypi    and   the   sarcomatous   forms   require    much   more 


288      THE    SURGICAL    DISEASES    OF    CHILDREN 

severe  measures.  Pedunculated  fibromata  may  be  re- 
moved by  the  galvano-cautery,  if  the  loop  can  be  passed 
over  the  pedicle.  If  this  is  impossible,  Mr.  Walsham 
recommends  that  the  soft  palate  should  be  split,  and  its 
edges  drawn  aside  by  threads  passed  through  them ;  and 
if  this  proceeding  fails  to  give  sufficient  room,  a  portion  of 
the  hard  palate  must  be  gouged  away,  until  the  polypus 
can  be  reached  with  a  snare.  The  edges  of  the  palate  are 
then  sutured  with  horsehair,  as  in  the  ordinary  operation 
for  the  repair  of  a  cleft.  In  either  case  the  base  of  the 
polypus  must  be  destroyed  by  the  actual  cautery.  Rouge's 
method  of  reflecting  the  upper  lip  and  detaching  the  alse 
nasi,  until  the  whole  of  the  anterior  nares  is  exposed,  is 
sometimes  serviceable  for  the  removal  of  polypi  which  are 
attached  more  anteriorly.  Sarcomata  can  only  be  extir- 
pated by  a  formal  removal  of  the  superior  maxilla,  either 
by  the  major  operation  of  excising  the  whole  bone,  or  less 
commonly  by  the  minor  operation,  which  consists  in  leav- 
ing the  orbital  plate.  The  operation  must  be  performed 
at  the  earliest  possible  opportunity,  and  for  this  reason  the 
earliest  recognition  of  the  growth  is  of  great  importance. 
This  can  be  effected  in  the  case  of  sarcomata  springing 
from  the  antrum  by  introducing  a  small  electric  light  into 
the  mouth  in  a  dark  room,  when  the  affected  antrum  will 
appear  less  translucent  than  its  fellow;  but  this  loss  of 
translucency  is  only  diagnostic  of  an  antral  tumour,  and  it 
may  be  due  to  an  abscess.  Electrolysis  is  sometimes  use- 
ful in  the  treatment  of  the  more  slowly  growing  tumours. 

RHINOLITH. 

Children  so  often  push  foreign  substances  into  the 
various  orifices  of  their  bodies,  that  it  is  not  surprising  if 
they  sometimes  remain  where  they  have  been  put,  and  are 
forgotten.     This  is  especially  the  case  with  foreign  bodies 


DISEASES  OF  THE  TONSILS,  PHARYNX,  AND  NOSE  289 

pushed  into  the  nose.  They  may  lie  there  for  years,  and 
become  encrusted  with  carbonate  and  phosphate  of  lime, 
intermixed  with  much  organic  matter,  until,  by  their  irri- 
tation, they  cause  a  discharge,  and  a  complete  blocking  of 
one  nostril.  All  cases  in  which  there  is  a  persistent  and 
foetid  discharge  from  one  nostril  should  be  examined  with 
a  view  to  detecting  the  presence  of  a  foreign  body,  and  it 
is  best  to  make  the  examination  under  an  anaesthetic.  The 
rhinolith  is  readily  detected,  and  the  only  thing  for  which 
it  is  then  likely  to  be  mistaken  is  a  piece  of  dead  bone, 
leading  to  ozaena. 

Treatment.— The  rhinolith  is  easily  dislodged  and 
removed  by  means  of  a  pair  of  dressing  forceps.  The 
nostril  should  be  washed  out  for  a  few  days  with  a  warm 
solution  of  boric  acid. 


U 


CHAPTER    XIV 
DEFORMITIES  AND  DISEASES  OF  THE  EAR 

SUPERNUMERARY  AURICLES. 

Supernumerary  auricles  or  pre-auricular  appendages  are 
by  no  means  uncommon.  Their  size  and  their  situation 
vary  greatly.  They  are  sometimes  mere  tags  of  skin, 
with,  or  more  often  without,  any  perceptible  elastic  or 
fibro-cartilage.  They  are  attached  immediately  in  front  of 
the  pinna  of  the  ear,  or  at  some  point  in  the  line  extending 
from  it  to  the  angle  of  the  mouth,  or  more  rarely  at  some 
distance  from  it,  on  the  cheek  of  the  same  side.  They 
bear  a  closer  resemblance  to  the  auricle  in  other  cases,  and 
are  situated  along  the  anterior  border  of  the  sterno-mastoid 
muscle,  either  opposite  the  thyro-hyoid  space,  or  immedi- 
ately above  the  sterno-clavicular  articulation.  They  may 
be  associated  with  the  remains  of  branchial  clefts,  in  which 
case  they  may  lie  above  a  minute  fistulous  opening  in  the 
skin.  They  are  either  single  or  multiple,  unilateral  or  bi- 
lateral, and  the  pinna  of  the  ear  upon  the  side  on  which 
they  grow  is  often  badly  developed.  Dr.  Ballantyne,27  who 
has  recently  studied  these  growths  with  great  care,  says 
that  they  are  so  often  associated  with  other  defects,  that 
probably  nearly  every  case  on  careful  search  will  reveal  at 
any  rate  minor  malformations  of  the  ear,  eye,  or  mouth, 
and  very  often  major  alterations  in  other  parts  of  the 
body. 

Pathology.— Mr.  Bland  Sutton  ingeniously  points  out 

2S0 


DEFORMITIES    AND    DISEASES    OF    THE    EAR     29 1 

that  the  pinna  may  be  regarded  as  an  enormously  de- 
veloped operculum,  modified  for  acoustic  purposes,  and  that 
some  supernumerary  auricles  may  be  looked  upon  as  per- 
sistent opercula,  or  coverings  to  the  primitive  gill-slits. 

Treatment. — No  harm  comes  from  their  immediate  and 
complete  removal,  even  in  the  youngest  children  ;  but  the 
surgeon  must  be  prepared  to  ligature  the  small  central 
vessel. 

HYPERTROPHY   OF   THE   PINNA. 

Hypertrophy  of  the  pinna  sometimes  causes  great  de- 
formity, for  the  ears  may  stand  out  or  flap  forwards. 

Treatment. — When  there  is  only  slight  deformity,  an 
attempt  may  be  made  to  keep  the  ears  in  position  by  means 
of  a  pair  of  pads,  connected  together  by  a  steel  spring  pass- 
ing over  the  top  of  the  head.  A  formal  operation  is  re- 
quired in  the  more  severe  cases.  Prof.  Keen  recommends 
that  a  good-sized  and  oval  flap  of  skin  should  be  removed 
from  the  back  of  the  auricle,  and  that  a  V-shaped  groove 
should  be  made  along  the  whole  length  of  the  cartilage. 
The  edges  of  the  wound  are  then  brought  together,  and 
as  soon  as  it  has  healed,  the  auricle  may  be  attached  to  the 
head  by  a  single  point-suture  so  as  to  keep  the  ear  in  place, 
until  cicatrization  is  sufficiently  advanced  to  render  such 
mechanical  means  unnecessary.  A  triangular  piece  of  the 
auricle  may  require  removal  in  still  more  severe  cases, 
the  apex  of  the  triangle  being  directed  towards  the 
meatus. 

ECZEMA  AURIS. 

Eczema  of  the  external  ear  is  a  very  chronic  affection, 
which  often  leads  to  total  occlusion  of  the  external  audi- 
tory meatus,  at  first  by  granulations,  and  afterwards  by 
dense  cicatricial  tissue.    It  is  often  associated  with  a  long- 


n 


292      THE    SURGICAL    DISEASES    OF    CHILDREN 

continued  discharge  through  the  meatus,  due  to  purulent 
inflammation  of  the  middle  ear. 

Treatment. — The  treatment  consists  in  removing  the 
granulations  with  a  sharp  spoon,  and  keeping  the  ear 
plugged  until  healing  takes  place  under  the  influence  of 
cod-liver  oil  and  grey  powder,  with  rhubarb.  A  little 
powdered  oxide  of  zinc  may  be  dusted  over  the  eczematous 
patches  two  or  three  times  a  day,  or  the  ear  may  be 
plugged  with  gauze  soaked  in  camphorated  naphthol. 

FOREIGN  BODIES  IN  THE  EAR. 

Foreign  bodies  in  the  ear  consist  of  the  various  sub- 
stances  introduced  by  children  into  the  external  auditory 
meatus.  Impacted  wax  in  the  ears  is  less  common  in 
children  than  in  adults,  for  in  children  the  cerumen  gene- 
rally becomes  fluid,  instead  of  forming  inspissated  masses. 
Children  are  somewhat  more  liable  to  blocking  of  the  ex- 
ternal auditory  meatus  by  plugs  of  epithelial  cells,  which 
are  densely  hard,  and  require  numerous  and  prolonged 
applications  of  a  1  in  10  solution  of  bicarbonate  of  soda 
before  they  can  be  softened. 

Treatment. — The  surgeon  must  first  ascertain  whether 
a  foreign  body  is  really  present  in  the  ear,  by  actual  inspec- 
tion with  an  otoscope  by  means  of  reflected  light,  and  he 
must  then  determine  its  nature. 

If  wax  alone  be  present,  it  should  be  washed  away  by  a 
gentle  stream  of  warm  boric  acid  lotion ;  but  if  it  is  hard, 
it  must  be  softened  in  the  ordinary  manner,  by  dropping 
a  little  warm  oil  into  the  meatus,  night  and  morning,  and 
then  gently  syringing  it  out  of  the  canal  as  soon  as  it  has 
become  softened. 

A  foreign  body  may  be  difficult  to  discover,  as  it  often 
lies  on  the  anterior  inferior  wall  of  the  meatus,  where  it  is 


DEFORMITIES    AND    DISEASES    OF    THE    EAR     293 

quite  concealed.  The  meatus  in  such  cases  must  be  care- 
fully explored  with  a  bent  probe. 

Insects  are  first  killed  by  filling  the  ear  with  olive  oil, 
which  suffocates  them  by  filling  their  tracheae,  and  they 
are  afterwards  syringed  out  of  the  ear  with  warm  water. 
Foreign  bodies  like  beads,  which  will  not  swell  when  they 
are  moistened,  may  be  removed  by  syringing.  In  each  case, 
the  child  is  so  placed  that  the  affected  ear  is  most  depend- 
ent, whilst  the  stream  of  water  is  directed  along  the  upper 
wall  of  the  meatus,  the  auricle  being  pulled  backwards  and 
upwards  to  convert  the  channel  into  a  straight  line. 

This  method  cannot  be  used  for  peas,  beans,  or  paper 
leads.  They  must  either  be  left  alone,  or  an  attempt  may 
be  made  to  extract  them  by  anaesthetising  the  child,  and 
introducing  a  loop  of  stout  silver  wire  with  the  greatest 
gentleness.  When  this  fails,  the  agglutinative  method 
may  be  employed  ;  but  I  have  never  had  recourse  to  it. 
The  child  is  put  to  bed,  and  a  camel-hair  brush  soaked  in 
a  little  glue  is  put  into  the  ear,  so  that  the  bristles  rest 
upon  the  foreign  body.  The  brush  is  withdrawn  as  soon 
as  the  glue  has  set.  It  is  sometimes  necessary  to  make  an 
incision  behind  the  ear  in  order  to  gain  access  to  the  exter- 
nal auditory  meatus,  when  the  foreign  body  may  be  ex- 
tracted with  a  pair  of  toothed  forceps  ;  but  sometimes  the 
wisest  plan  is  to  let  them  alone. 

CHRONIC   PURULENT  INFLAMMATION   OF 
THE  MIDDLE  EAR. 

Etiology. — Otorrhoea  is  one  of  the  most  frequent  and 
troublesome  conditions  met  with  in  children.  It  occurs 
from  many  causes,  and  if  it  is  not  due  to  the  impaction  of 
foreign  bodies,  or  to  growths  in  the  external  auditory 
meatus,    it   is   most   frequently   caused   by   otitis  media. 


294      THE    SURGICAL    DISEASES    OF    CHILDREN 

Rasch,  of  Copenhagen,  found  evidence  of  middle  ear  disease 
in  no  less  than  70  cases  out  of  82  autopsies  made  upon  the 
bodies  of  children  under  two  years  of  age,  whilst  Kassel 
found  it  in  85  cases  out  of  108  children  under  one  year, 
who  had  died  of  various  diseases. 

The  affection  may  begin  as  a  chronic  suppurative  in- 
flammation, apparently  without  cause ;  but  its  origin  is 
much  more  frequently  referred  to  an  attack  commencing 
during  measles,  scarlet  fever,  or  diphtheria,  or  to  some 
chronic  or  infective  inflammation  of  the  naso-pharynx.  It 
appears  to  be  especially  frequent  after  broncho-pneumonia, 
when  it  leads  to  deafness  without  perforation,  and  is  then 
very  likely  to  be  overlooked. 

Dr.  Walker  Downie,a9  in  a  recent  and  interesting  paper 
upon  inflammation  of  the  middle  ear,  in  connection  with 
the  exanthemata,  is  inclined  to  think  that  the  increased 
tendency  to  suppuration  in  these  cases  can  be  explained 
mechanically.  He  says  that  when  a  child  is  suffering 
from  measles  or  scarlet  fever  he  is  confined  to  bed  day 
and  night,  so  that  during  the  greater  part  of  the  twenty- 
four  hours  he  lies  on  his  back.  This  position  favours  the 
retention  of  secretions  within  the  hollow  of  the  naso- 
pharynx, whilst  from  the  altered  direction  of  the  Eusta- 
chian tubes,  the  inflammatory  products  in  the  middle  ear 
are  unable  to  escape,  even  supposing  the  tube  to  remain 
patent.  The  consequences  are  that  the  catarrhal  inflam- 
mation accompanying  measles  and  scarlet  fever  is  soon 
followed  by  suppuration,  the  lining  membrane  of  the 
tympanum  becomes  necrosed,  the  tympanic  membrane  is 
ruptured,  and  the  bony  cells  surrounding  and  communi- 
cating with  the  tympanum  are  filled  with  the  products  of 
suppuration.  Damp  and  insanitary  surroundings  also 
appear  to  exercise  a  great  influence  in  the  causation  of 
otitis  media,  by  the  depressing  effects  which  they  exercise 


DEFORMITIES    AND    DISEASES    OF    THE    EAR     295 

upon  the  general  health,  leading  to  an  increased  predis- 
position to  infective  diseases. 

Pathology. — Dr.  Blaxall's  investigations  show  that  the 
most  potent  factor  in  the  production  of  otitis  media,  follow- 
ing scarlet  fever,  is  the  streptococcus  pyogenes,  and  that  the 
next  most  important  organisms  are  the  staphylococci,  albus 
et  aureus.  The  diplococcus  pneumoniae  of  Talamon  and 
Fraenkel,  and  the  bacillus  pneumoniae  of  Friedlander,  may 
however  accompany  the  inflammation  in  those  forms  which 
are  not  due  to  scarlet  fever. 

Morbid  Anatomy.  — Politzer  describes  very  carefully 
the  changes  which  take  place  in  the  various  parts  of  the 
ear,  as  a  result  of  chronic  suppurative  inflammation.  The 
mucous  membrane  of  the  Eustachian  tube  is  swollen,  the 
epithelial  cells  proliferate,  and  the  mucous  glands  enlarge ; 
but  it  is  unusual  to  meet  with  polypoid  granulations. 

The  mucous  membrane  in  the  middle  ear  is  at  first  much 
thickened  by  the  formation  of  inflammatory  tissue,  whilst 
the  mucous  glands  and  the  blood-vessels  are  greatly  in- 
creased in  size.  There  is  a  formation  of  new  connective 
tissue  in  the  later  stages,  associated  with  polypoid  masses 
of  granulation  tissue  which  spring  from  the  ulcerated 
parts  of  the  mucous  membrane. 

The  membrana  tympani  is  most  frequently  ulcerated  at 
that  part  which  is  situated  midway  between  the  periphery 
and  the  handle  of  the  malleus.  The  perforation  is  not 
always  easy  to  see,  for  the  membrane  may  be  swollen 
and  thickened.  Prof.  Politzer  therefore  recommends  that 
in  cases  where  the  existence  of  a  perforation  is  doubt- 
ful, the  external  auditory  meatus  should  be  filled '  with 
warm  water,  and  air  should  be  forced  through  the  Eustach- 
ian tube  by  means  of  his  bag.  Air  will  then  bubble 
through  the  water  if  the  membrana  tympani  be  perforated. 
When  the  suppuration  has  ceased,  the  perforation  either 


296      THE    SURGICAL    DISEASES    OF    CHILDREN 

remains  as  a  permanent  orifice,  or  it  becomes  closed  by  a 
delicate  film  of  scar  tissue. 

The  inflammation  extending  to  the  external  ear  often 
leads  to  a  condition  of  eczema  (p.  291),  to  cicatricial  con- 
traction and  narrowing  of  the  orifice,  to  polypi,  or  to  a 
dense  mass  of  granulations  which  may  eventually  cause 
obliteration  of  the  external  auditory  meatus. 

Symptoms.— The  symptoms  are  seldom  well  defined. 
There  is  often  pain,  which  is  worse  at  one  time  than  at 
another,  owing  to  intercurrent  attacks  of  acute  inflammation. 
There  is  also  local  tenderness  beneath  the  pinna  of  the  ear. 
The  headache  is  usually  either  lateral  or  occipital ;  and  if 
caries  of  the  temporal  bone  has  taken  place,  there  may  be 
giddiness,  vomiting,  unsteady  gait,  and  increased  tinnitus. 
The  impairment  of  hearing  is  generally  very  marked,  and 
there  may  be  alterations  in  taste  and  smell,  though  as  no 
complaint  is  made  spontaneously  by  the  patient,  they  are 
only  to  be  ascertained  by  testing  these  senses. 

The  discharge  may  be  bilateral ;  it  occurs  after  the  mem- 
brana  tympani  is  ruptured,  and  it  lasts  for  an  indefinite 
period.  It  varies  greatly  in  quantity  and  in  colour,  and  it 
always  contains  micro-organisms.  Perforation  of  the  mem- 
brana  tympani  usually  takes  place  early.  The  aperture  is 
generally  single,  and  is  round,  oval,  or  elliptical  in  shape. 

The  inflammation  runs  a  very  protracted  course,  and  the 
suppuration  usually  continues  uninterruptedly,  though  it 
sometimes  ceases  spontaneously  to  return  after  weeks, 
months,  or  years,  with  or  without  acute  symptoms.  These 
relapses  are  often  due  to  cold,  to  naso-pharyngeal  catarrh, 
to  the  exanthemata,  or  to  the  entrance  of  water  into  the 
middle  ear  through  an  unclosed  perforation.  It  is  well, 
therefore,  to  warn  boys  who  have  been  temporarily  cured  of 
otorrhoea  due  to  middle  ear  disease  to  avoid  plunge  baths, 
unless  they  put  a  piece  of  cotton  wool  into  their  ears,  and 


DEFORMITIES    AND    DISEASES    OF    THE    EAR     297 

to  recommend  them  not  to  practise  diving  from  a  height 
under  any  circumstances.  The  discharge  ceases  in  many 
children  during  the  summer,  and  returns  again  in  autumn. 

The  chronic  nature  of  the  disease  appears  to  be  due  to 
the  retention  of  the  purulent  exudation  in  the  various  re- 
cesses of  the  middle  ear,  though  it  is  partly  accounted  for 
by  the  periostitis  and  caries  of  the  temporal  bone,  with 
which  it  is  often  associated,  and  partly  by  the  continuance 
of  the  original  source  of  infection  in  the  naso-pharynx. 

Prognosis. — The  prognosis  is  always  uncertain  so  long 
as  the  discharge  continues.  It  is  unfavourable  when  the 
otorrhoea  is  profuse  and  is  persistently  septic.  It  is  favour- 
able when  the  discharge  has  ceased,  so  long  as  the  hearing 
improves.  The  prognosis  for  the  recovery  of  the  hearing  is 
favourable  if  the  hearing  distance  remains  stationary,  but 
unfavourable  if  there  are  continual  subjective  noises,  or  if 
there  is  a  diminution  in  the  sense  of  hearing  conducted 
sounds,  as  tested  by  a  tuning-fork  placed  upon  the  head. 

Diagnosis. — Otitis  media  sometimes  simulates  menin- 
gitis very  closely,  especially  in  children  who  are  too  young 
to  indicate  the  seat  of  their  pain.  There  is  sometimes 
marked  retraction  of  the  head.  The  symptoms  in  otitis, 
however,  are  often  markedly  relieved  by  puncturing  the 
membrana  tympani  and  by  inflating  the  Eustachian  tubes, 
whilst  such  treatment  is  ineffectual  in  meningitis. 

Treatment. — The  treatment  consists  in  keeping  the 
middle  and  the  external  ear  scrupulously  clean,  and  it  is 
the  great  difficulty  in  doing  this  which  makes  the  cases 
so  intractable. 

Dr.  Walker  Downie  says  20  that  in  the  exanthemata  from 
the  very  beginning  of  the  illness,  where  there  are  any 
catarrhal  symptoms,  the  patient  should  be  directed  to  use 
his  pocket-handkerchief  frequently  and  strongly,  and  the 
attendant  nurse  should  be  instructed  to  see  that  he  does 


298      THE    SURGICAL    DISEASES    OF    CHILDREN 

so.  By  this  means  the  nasal  discharge  is  got  rid  of 
through  the  anterior  nares,  and  the  air,  in  passing  with 
considerable  force  from  the  lungs  towards  the  nose,  helps 
to  loosen  and  to  dislodge  any  discharge  lying  in  the  naso- 
pharynx. Politzer's  inflation  bag  should  be  used  when 
the  child  is  too  young  to  blow  its  nose  efficiently,  or  when 
the  tonsils  are  enlarged,  or  the  patient  has  adenoids.  The 
quantity  of  secretion  dislodged  and  thrown  into  the  mouth 
by  such  inflation  is  very  remarkable.  One  or  other  of 
these  methods  should  be  employed,  in  every  case,  without 
waiting  for  the  appearance  of  symptoms  pointing  to  im- 
plication of  the  ear.  When,  on  the  other  hand,  there  is 
dulness  of  hearing,  and  when  there  are  sounds  or  pains  in 
the  ears,  resort  to.  inflation  should  never  be  delayed,  as 
these  symptoms  point  to  closure  of  the  Eustachian  tubes, 
and  to  retention  of  secretion  within  the  middle  ear,  and 
relief  may  be  instantaneously  secured  in  the  majority  of 
cases  by  complete  inflation. 

Inflation. — There  are  many  methods  of  inflating  the 
middle  ear,  for  there  are  many  ways  of  opening  the  Eusta- 
chian tubes  at  the  instant  when  the  blast  of  air  is  forced 
out  of  Politzer's  bag.  The  child  may  be  placed  in  a  re- 
cumbent or  sitting  position,  and  the  tube  from  the  bag  is 
placed  in  one  nostril  whilst  the  opposite  one  is  closed,  and 
he  is  directed  to  say  "  hie,  hsec,  hoc,"  when  the  bag  is  com- 
pressed. This  method,  serviceable  enough  for  young  adults, 
is  useless  in  children,  and  for  them  the  bag  must  be  gently 
squeezed  whilst  the  child  blows  through  a  narrow  tube  with 
sufficient  force  to  distend  the  cheeks.  Dr.  Dundas  Grant 
suggests  that  a  pipe-stem  or  a  Eustachian  catheter  answers 
the  purpose  very  effectually.  Air  or  steam,  impregnated 
with  a  minimum  of  chloroform  vapour,  passes  more  easily 
into  the  Eustachian  tubes  than  it  would  otherwise  do. 

Myringotomy. — When   there   is  very   great   pain,  and 


DEFORMITIES    AND    DISEASES    OF    THE    EAR      299 

the  symptoms  point  to  acute  tension  within  the  ear,  great 
relief  is  often  obtained  by  counter  -  irritation,  by  local 
blood-letting,  and  by  puncturing  the  tympanic  membrane. 
The  operation  is  a  simple  one.  The  child  is  placed  in  a 
good  light,  and  his  head  is  held  steadily  by  an  assistant. 
The  surgeon  reflects  light  into  the  external  auditory 
meatus  from  a  laryngoscope  mirror,  until  he  obtains  a 
good  view  of  the  swollen  drum.  He  then  makes  a  slit  into 
the  lower  and  posterior  portion  where  the  bulging  is  most 
prominent.  Proper  myringotomes  are  sold  for  the  pur- 
pose, but  a  straight  and  sharp-pointed  eye-needle,  such  as 
is  used  for  paracentesis  cornese,  does  perfectly  well. 

When  the  discharge  has  become  chronic  and  is  very  pro- 
fuse, the  ear  must  be  syringed  out  three  or  four  times  a 
day  with  boiled  water  at  a  temperature  of  80°  F.,  twice 
a  day  being  sufficient  after  the  first  day  or  two.  If  the 
discharge  be  excessive,  four  or  five  drops  of  oil  of  turpentine 
may  be  added  to  each  eight  ounces  of  water.  A  1  in  1000 
solution  of  perchloride  of  mercury  may  be  substituted 
when  the  discharge  is  very  offensive.  A  2  per  cent,  solu- 
tion of  peroxide  of  hydrogen,  or  a  5  per  cent,  watery  solu- 
tion of  resorcin,  has  also  given  me  good  results.  All  the 
solutions  should  be  used  warm,  as  they  are  less  apt  to 
produce  giddiness  than  when  they  are  injected  cold.  Very 
tenacious  secretions  may  be  removed  with  cotton-wool 
twisted  round  a  probe. 

Dr.  Rattel  claims  that  the  following  method  is  useful  in 
cases  of  very  chronic  suppuration  when  there  are  granula- 
tions. Its  great  objection  seems  to  be  that  the  amount  of 
the  douche  is  so  large.     His  formula  is  : — 

]}>     Chloral  hydrate,  1  drachm. 
Biborate  of  soda,  Ik  drachms. 
Water,  1  pint. 

Dissolve  and  make  a  lotion. 


300      THE    SURGICAL    DISEASES    OF    CHILDREN 

A  pint  of  this  solution  is  to  be  gently  injected  into  the 
ear  night  and  morning.  The  hydrate  of  chloral,  he  says, 
is  partially  decomposed  by  the  alkaline  borax  into  chloro- 
form and  formiate  of  soda,  so  that  the  solution  is  both 
sedative  and  antiseptic.  The  granulating  surfaces  are  also 
to  be  touched  three  or  four  times  a  week  with  a  1  in  30 
solution  of  zinc  chloride  applied  to  the  middle  ear  by  means 
of  a  Toynbee's  speculum.  The  ear  must  be  carefully  dried 
after  every  application,  and  a  piece  of  cotton-wool  should 
be  introduced  into  the  ear. 

Local  remedies  must  be  discontinued  as  soon  as  the  sup- 
puration has  ceased,  for  they  have  a  tendency  to  bring  it 
on  again.  A  little  boric  acid  may  be  insufflated  once  or 
twice  a  week  when  there  appears  to  be  any  likelihood  of 
a  relapse,  and  the  occasional  instillation  of  a  few  drops  of 
warm  alcohol  is  often  productive  of  the  greatest  benefit. 

Scarlatinal  Otitis. 

The  worst  form  of  chronic  suppuration  occurs  in  scarlet 
fever,  especially  if  it  be  associated  with  acute  membranous 
inflammation  of  the  naso-pharynx.  The  inflammation 
begins  at  the  height  of  the  disease,  and  is  marked  by  very 
severe  pain  with  rise  of  temperature  and  an  increase  in 
all  the  cerebral  symptoms.  Perforation  of  the  tympanic 
membrane  takes  place  early.  The  course  of  the  disease  is 
usually  very  protracted,  but  it  may  be  shortened  by  in- 
cising the  tympanic  membrane,  within  the  first  twenty- 
four  hours  after  the  onset  of  the  symptoms,  in  the  manner 
described  at  page  298. 

Severe  deafness  often  remains,  owing  to  the  inflamma- 
tion spreading  to  the  internal  ear  ;  and  if  this  occurs  in 
young  children,  they  may  never  learn  to  speak,  and  so 
remain  deaf  and  dumb. 


DEFORMITIES    AND    DISEASES    OF    THE    EAR      3OI 

Treatment. — The  treatment,  after  incision  of  the  tym- 
panic membrane,  consists  in  filling  the  ear  with  lime- 
water,  which  should  be  allowed  to  remain  in  the  external 
auditory  meatus  for  ten  minutes,  in  order  to  loosen  the 
membrane.  The  ear  should  then  be  gently  syringed  with 
sterilised  water,  carefully  dried,  and  afterwards  filled  with 
powdered  boric  acid.  This  proceeding  must  be  repeated 
three  or  four  times  a  day. 

Typhoidal  Otitis. 

Inflammation  also  occurs  secondarily  to  typhoid  fever  ; 
the  symptoms  usually  begin  during  the  fourth  or  fifth 
week  of  the  disease,  though  they  may  appear  much  earlier. 
Severe  deafness  may  continue  for  a  long  time,  but  fairly 
good  hearing  is  usually  regained. 

Otitis  after  Influenza. 

Inflammation  of  the  middle  ear  sometimes  occurs  after 
influenza.  A  child  of  a  year  old  was  brought  to  me  in 
February,  1894,  suffering  from  a  mastoid  abscess,  which 
his  mother  attributed  to  the  influenza  from  which  he  had 
suffered  six  weeks  previously.  The  pain  is  very  severe, 
and  is  not  relieved  by  the  rupture  or  perforation  of  the 
membrana  tympani.  There  is  protracted  suppuration,  and 
a  great  tendency  to  the  formation  of  a  mastoid  abscess 
with  rapidly  extending  caries,  which  renders  early  opera- 
tive interference  very  necessary.  A  fatal  termination 
from  meningitis,  cerebral  abscess,  and  thrombosis  of  the 
sinuses,  is  not  uncommon. 

Otitis  ix  Tubercle  and  Syphilis. 

Suppuration  of  the  middle  ear  may  follow  tubercle  or 
syphilis,  but  in  either  case  there  are  other  manifestations 
of  the  constitutional  condition.     There  is  but  little  pain  in 


2,02      THE    SURGICAL    DISEASES    OF    CHILDREN 

tuberculous  otitis,  and  perforation  does  not  usually  take 
place,  so  that  the  condition  may  be  overlooked  until  the 
occurrence  of  facial  paralysis  renders  a  more  careful  ex- 
amination imperative.  The  superficial  and  deep  lymphatic 
glands  near  the  mastoid  are  then  found  to  be  affected. 
There  is  often  very  great  destruction  of  the  petrous  portion 
of  the  bone ;  and  when  the  case  has  terminated  fatally,  the 
autopsy  may  show  that  the  base  of  the  skull  has  been 
transversely  involved,  so  that  an  inflammation  of  the  op- 
posite ear  may  be  the  result  of  a  direct  extension  of  the 
tuberculous  process. 


CHAPTER    XV 

DISEASE   OF   THE   TEMPORAL   BONE 

AND    THE    CEREBRAL    INFLAMMATIONS 

ARISING   FROM   IT 

Infective  inflammation  of  the  temporal  bone  usually 
affects  its  mastoid  and  temporal  portions.  It  either  begins 
as  a  periostitis,  associated  with  osteomyelitis,  rapidly  run- 
ning on  to  the  formation  of  an  abscess  behind  the  ear,  or 
it  is  the  result  of  the  extension  of  inflammation  from  the 
middle  ear,  leading  to  disease  of  the  bone,  and  perhaps 
spreading  to  the  brain  or  its  membranes. 

ACUTE  MASTOID   OSTEOMYELITIS. 

Symptoms. — The  more  superficial  form  of  disease  lead- 
ing to  mastoid  abscess  is  characterised  by  severe  pain, 
increased  when  the  patient  lies  down.  There  is  much  con- 
stitutional disturbance,  owing  to  the  unyielding  nature  of 
the  tissues  overlying  the  mastoid  process,  and  this  may  be 
accompanied  by  vertigo,  with  vomiting  of  a  cerebral  type 
— that  is  to  say,  without  nausea.  There  is  great  irrita- 
bility of  the  nervous  system,  acceleration  of  pulse,  rise  of 
temperature,  rigors,  tinnitus,  dizziness,  sleeplessness,  and 
occasional  excitement.  The  skin  over  the  mastoid  process 
is  infiltrated  and  swollen.  It  pits  upon  pressure,  and 
beneath  it  is  a  hard  swelling,  in  which  it  is  sometimes 
easy  and  sometimes  impossible  to  detect  fluctuation.  The 
swelling  is  itself  very  tender,  and  it  tilts  the  pinna  of  the 

303 


304      THE    SURGICAL    DISEASES    OF    CHILDREN 

ear  forward  in  a  manner  which  can  hardly  be  mistaken 
for  anything  else.  The  swelling  may  extend  above  the 
mastoid  process  into  the  temporal  region,  and  it  may  lead 
to  bulging  of  the  posterior  wall  of  the  external  auditory 
meatus  to  such  an  extent  as  to  close  its  lumen. 

Treatment.— The  swelling  should  be  incised  at  once, 
and  if  possible  before  suppuration  has  taken  place.  When 
an  abscess  has  formed,  its  contents  should  be  gently 
scraped  away,  and  it  should  be  packed  with  lint  soaked 
in  camphorated  naphthol  (p.  8).  It  may  open  spon- 
taneously after  some  weeks,  if  it  is  left  untreated,  leaving 
a  sinus ;  or  it  may  make  its  way  backwards,  to  form  a 
retropharyngeal  abscess,  or  forwards  into  the  glenoid 
cavity,  eventually  causing  unilateral  anchylosis  of  the 
lower  jaw.  The  fistulas  are  sometimes  very  long  in  heal- 
ing, but  they  rarely  lead  to  more  extensive  trouble.  They 
should  be  scraped  and  dressed  antiseptically. 

CHRONIC   MASTOID  DISEASE.30 

Chronic  infective  disease  of  the  middle  ear  is  the  most 
fertile  source  of  extensive  disease  of  the  temporal  bone, 
though  tuberculous  disease  occasionally  causes  it.  It  is  of 
very  frequent  occurrence  in  children ;  for  during  the  last 
four  years  more  than  thirty  cases  of  disease  of  the  tem- 
poral bone,  connected  with  ear  trouble,  have  been  admitted 
to,  and  operated  upon  in  the  wards  of  the  Victoria 
Hospital  for  Children. 

Morbid  Anatomy.— The  inflammation  of  the  middle 
ear  extends  either  upwards  or  backwards,  and  in  children 
it  usually  passes  along  the  suture  of  the  petrous  with  the 
squamous  portion  of  the  temporal  bone,  or  it  may  spread 
through  the  bone  itself.  The  dura  mater  may  thus  be- 
come involved  in  the  inflammatory  process,  which  actually 


CEREBRAL    ABSCESS  2>°5 

destroys  the  bone  and  leads  to  thrombosis  of  the  lateral 
sinus. 

CEREBRAL  ABSCESS. 

Cases  of  long-standing  inflammation  of  the  middle  ear 
and  of  the  mastoid  process  sometimes  terminate  in  an 
abscess,  formed  in  the  white  matter  of  the  brain ;  either 
in  the  temporo-sphenoidal  lobe,  or  about  half  as  often  in 
the  cerebellum,  though  in  rarer  cases  the  abscess  is  formed 
between  the  dura  mater  and  the  pia  mater.  These  ab- 
scesses are  always  single.  They  vary  greatly  in  size,  some 
only  containing  a  few  drops  of  pus,  whilst  others  may 
contain  several  ounces,  and  they  may  open  into  the  lateral 
ventricle.  Some  observers  think  that  they  are  a  little 
more  common  on  the  right  than  upon  the  left  side,  owing 
to  the  greater  size  of  the  right  lateral  sinus,  which  is  thus 
more  likely  to  be  involved  in  the  inflammatory  process. 
The  abscesses  usually  cause  death,  unless  they  are  opened 
by  surgical  means ;  but  they  occasionally  discharge  their 
contents  through  the  external  ear,  or  even  through  the 
side  of  the  skull.  Sometimes  they  become  encysted,  and, 
under  exceptional  conditions,  they  may  be  absorbed.  The 
pus  varies  in  colour,  it  is  usually  bloodstained ;  but  it  may 
be  greenish-j^ellow,  and  it  is  sometimes  foetid  and  thin. 

Causes. — Cerebral  abscess  may  also  follow  a  compound 
fracture  of  the  skull,  when  it  is  more  frequent  in  the  upper 
and  anterior  parts  of  the  brain ;  or  it  may  arise  from 
general  infective  conditions,  as  in  pyaemia,  occurring  in 
connection  with  foetid  bronchitis,  empyema,  infective  peri- 
tonitis, or  osteomyelitis  of  the  long  bones. 

Symptoms. — The  symptoms  of  cerebral  abscess  in  con- 
nection with  middle  ear  disease  are  tolerably  well  defined, 
though  cases  occasionally  occur   in   which   the  most  ex- 

x 


306     THE    SURGICAL    DISEASES    OF    CHILDREN 

perienced  surgeons  are  mistaken.  The  typical  history  is, 
that  a  child,  who  has  long  been  suffering  from  a  stinking 
otorrhoea,  catches  cold,  or  receives  a  blow  on  the  side  of 
the  head.  He  complains,  either  in  a  few  hours  or  after 
some  days  or  weeks,  of  severe  headache,  at  first  localised, 
but  later  extending  all  over  the  side  of  the  head.  The  pain 
is  accompanied  by  vomiting  of  the  ordinary  cerebral  type. 
There  is  generally  a  single  rigor,  and  the  temperature  is 
so  little  above  the  normal  that  the  surgeon  may  be  thrown 
off  his  guard  if  he  trust  too  much  to  the  thermometric 
indications.  The  discharge  from  the  ear  either  diminishes 
in  quantity,  or  may  disappear  entirely.  The  parents,  look- 
ing only  to  the  pain  without  taking  the  trouble  to  localise 
it,  as  a  rule  think  that  these  symptoms  are  due  to  a  fresh 
attack  of  the  earache,  to  which  the  child  has  long  been 
liable.  They  neglect  to  seek  advice,  and  so  this  early  stage 
of  the  disease  rarely  comes  tinder  the  notice  of  the  surgeon. 
In  a  few  cases,  a  cerebral  abscess  is  formed  in  connection 
with  an  acute  inflammation  of  the  middle  ear. 

The  violent  pain  subsides  after  a  time,  but  the  patient 
is  so  listless  and  drowsy  that  he  is  kept  in  bed,  and  as 
long  as  he  is  recumbent  he  does  not  vomit.  Examination 
now  shows  distinct  evidence  of  intracranial  pressure  :  the 
temperature  becomes  sub-normal,  the  pulse  is  slow  and 
full,  the  respirations  are  slow  and  regular — slower  and 
more  sighing  in  cerebellar  abscess  than  in  the  cerebral 
form.  There  is  well-marked  tenderness  over  the  temporal 
bone  on  the  affected  side,  and  this  tenderness  is  readily 
elicited  by  gently  tapping  the  skull  with  the  finger,  but 
there  is  not  necessarily  any  oedema  or  swelling.  The  breath 
is  often  foetid,  and  there  may  be  a  rapidly  advancing  optic 
neuritis.  An  endeavour  should  be  made  at  this  stage 
to  ascertain  the  position  of  the  abscess,  for  Macbride  be- 
lieves that,  if   the   conduction  of   sound  by  the   bone  is 


CEREBRAL    ABSCESS  2>Oy 

impaired,  owing  to  disease  of  the  labyrinth,  the  abscess  is 
more  likely  to  be  in  the  cerebellum  than  in  the  temporo- 
sphenoidal  lobe  of  the  brain.  The  condition  of  cerebral 
irritation,  which  is  often  indicated  by  twitching  of  the 
muscles,  soon  passes  into  paralysis  ;  the  patient  becomes 
first  stupid  and  then  comatose,  the  pulse  becomes  quick, 
the  temperature  rises  rapidly,  convulsions  occur,  and  death 
soon  terminates  the  case,  unless  the  abscess  is  emptied. 
Prof.  Macewen  states  that  he  is  able  to  elicit  a  differential 
cranial  percussion  note  in  children  with  cerebral  abscess  ; 
the  patient  is  supported  upright  in  bed,  and  gentle  percus- 
sion is  made  over  the  pterion  on  the  two  sides.  I  have 
several  times  endeavoured  to  elicit  this  difference,  but  my 
ear  is  not  }*et  sufficiently  trained  to  observe  it. 

Diagnosis. — The  diagnosis  of  cerebral  abscess  has  to 
be  made  from  cerebral  inflammation  of  a  more  diffuse 
nature,  from  diffuse  serous  meningitis,  from  infective 
thrombosis  of  the  lateral  sinus,  and  from  cerebral  tumour. 
The  absence  of  delirium  or  nerve-paralysis,  the  low 
temperature  until  the  later  stages,  and  the  absence  of 
rigidity  in  the  muscles  of  the  neck,  are  the  chief  points 
by  which  to  recognise  a  cerebral  abscess.  They  are  all 
negative,  however,  and  they  are  merely  symptoms  of  in- 
creased intracranial  pressure,  so  that  they  are  very  apt  to 
prove  fallacious. 

Prognosis. — The  prognosis  is  always  grave,  for  unless 
surgical  treatment  be  adopted  early,  a  cerebral  abscess 
generally  ends  fatally.  An  untreated  acute  abscess  runs 
its  course  in  two  to  six  weeks,  whilst  a  chronic  abscess 
may  last  as  many  months  or  years. 

Treatment. — The  treatment  is  prophylactic  or  curative. 
The  prophylactic  measures  have  already  been  dealt  with 
(pp.  297,  298)  in  the  simple  forms ;  and  if  they  fail,  the 
parts  must  be  rendered  as  thoroughly  aseptic  as  possible, 


308      THE    SURGICAL    DISEASES    OF    CHILDREN 

in  every  case  in  which  it  is  likely  that  a  cerebral  abscess 
may  be  formed.  This,  of  course,  is  in  every  case  of  long- 
continued  stinking  otorrhcea  associated  with  disease  of  the 
middle  ear.  The  only  way  to  meet  this  indication  is  to 
cut  away  a  portion  of  the  compact  tissue,  forming  the  front 
wall  of  the  mastoid  process,  as  soon  as  the  ordinary  methods 
of  arresting  the  discharge  have  failed.  There  need  be  the 
less  hesitation  in  doing  this,  as  the  operation  is  neither 
difficult  nor  dangerous,  if  ordinary  care  and  skill  be  em- 
ployed, and  it  is  attended  with  the  most  satisfactory  results. 
Professor  Macewen,  following  Professor  Schwartze's  indica- 
tions, states  that  it  is  justifiable  to  open  the  mastoid 
antrum  when  :  (1)  There  has  been  repeated  inflammation 
of  the  mastoid  antrum  and  its  cells,  accompanied  by  swell- 
ing over  the  mastoid  process,  or  when  there  is  a  fistulous 
opening  in  the  bone,  from  which  pus  is  discharging.  (2)  In 
acute  inflammation  of  the  mastoid  antrum  and  its  cells, 
with  retention  of  pus.  (3)  When  there  are  initial  symp- 
toms of  intracranial  disease,  associated  with  chronic  and 
purulent  otorrhcea.  Finally,  where  there  is  a  persistent 
otorrhcea,  especially  if  it  be  offensive,  and  if  the  discharge 
is  mixed  with  bony  particles  or  steatomatous  masses. 
These  rules  apply  equally  to  childi^en  and  to  adults. 

Opening  the  Mastoid  Cells. — The  operation  of  opening 
the  mastoid  cells  was  first  performed  by  J.  L.  Petit  in 
1750,  though  Jasser,  a  German  army  surgeon,  usually  has 
the  credit  of  introducing  it  in  1776. 

The  mastoid  antrum  is  the  point  to  be  aimed  at  in 
young  adults,  for  it  communicates  on  the  one  hand  with 
the  middle  ear,  and  it  is  only  separated  from  the  middle 
fossa  of  the  skull  by  a  thin  shell  of  bone.  It  is  therefore 
one  of  the  points  through  which  inflammatory  processes 
are  most  likely  to  extend  directly  from  the  ear  to  the  dura 
mater.      In   children   there   is   practically  only   a  single 


EXPLORATION    OF    MASTOID    PROCESS        309 

large  cell  in  the  mastoid  process,  so  that  the  pus  is  obvious 
as  soon  as  the  outer  wall  of  the  bone  is  gouged  away. 

The  patient  should  be  properly  prepared  for  the  opera- 
tion by  shaving  the  side  of  the  head  the  day  before  the 
operation,  scrubbing  it  thoroughly  with  soap  and  water, 
and  afterwards  with  ether.  It  should  then  be  covered 
with  a  dressing  soaked  in  1  in  1000  solution  of  corrosive 
sublimate,  kept  in  place  by  a  gauze  bandage  until  the  opera- 
tion begins.  The  parts  should  be  again  washed  when  the 
patient  is  under  the  anesthetic,  and  rubbed  over  with  a 
one  pro  mille  solution  of  corrosive  sublimate  in  alcohol. 

A  perpendicular  linear  incision  is  then  made  a  quarter 
of  an  inch  behind  the  posterior  border  of  the  external 
auditory  meatus.  All  the  tissues,  including  the  perios- 
teum, should  be  divided  until  the  bone  is  reached,  and  it 
is  a  golden  rule  to  expose  the  posterior  bony  edge  of  the 
external  auditory  meatus,  since  this  border  serves  as  a 
landmark  throughout  the  operation.  The  cancellous  tissue 
of  the  mastoid  process  must  be  exposed  by  gouging  away 
the  bone  upwards  and  a  little  forwards,  at  the  same  time 
remembering  that  the  bone  is  very  thin,  and  that,  unless 
great  care  be  taken,  the  dura  mater,  the  lateral  sinus,  and 
even  the  brain  itself,  may  be  exposed  and  injured.  This 
is  especially  likely  to  happen  in  cases  of  long-standing 
inflammation,  in  which  the  outer  layer  of  compact  bone 
may  become  as  dense  as  ivory.  The  cavity  of  the  mastoid 
should  be  thoroughly  cleansed,  and  any  epithelial  masses 
■or  caseating  material  should  be  removed.  No  drainage-tube 
is  required  if  this  be  done  thoroughly,  and  if  the  diseased 
skin  be  cut  away  with  a  scalpel.  The  side  of  the  head  is 
subsequently  enveloped  in  antiseptic  lint,  with  gauze  ban- 
dages, and  the  wound  is  dresseil  frequent]}'  if  there  is 
much  discharge. 

During  the  operation  the  following  anatomical  points 


3IO      THE    SURGICAL    DISEASES    OF    CHILDREN 

may  be  borne  in  mind  : — The  facial  nerve  lying  in  the 
aqueductus  Fallopii  generally  crosses  the  inner  half  of 
the  floor  of  the  mastoid  antrum,  running  obliquely  from 
without  inwards ;  the  lateral  sinus  is  in  very  close 
proximity  to  the  roof  of  the  space,  which  is  sometimes 
defective  as  a  result  of  the  ulcerative  process,  and  con- 
sequently granulations  in  this  region,  which  appear  to 
be  of  the  ordinary  type,  may  in  reality  spring  from  the 
dura  mater. 

Professor    Birmingham   gives   the   following   rules   for 
finding,  and  for  avoiding  the  lateral  sinus  in  an  adult  : 
'  The  lateral  sinus   can  always  be  exposed   by  a  three- 
quarter-inch  trephine,  if  its  pin  be  placed  an  inch  and 
an  eighth  behind  the  centre  of  the  bony  meatus,  and  in 
the  line  of  its  upper  border.     To  avoid  the  sinus,  a  perfora- 
tion behind  the  ear  should  be  made,  in  front  of  a  vertical 
line  drawn  a  quarter  of  an  inch  behind  the  posterior  mar- 
gin of  the  meatus.     The  mastoid  antrum  can  always  be 
reached   without    wounding   the   sinus   or   entering    the 
cranial  cavity,  if  a  quarter-inch  drill  is  sent  straight  in 
at  such  a  point  that  the  anterior  margin  of  the  aperture 
it  makes  is  as  close  as  possible  to  the  bony  meatus,  whilst 
its  upper  margin  is  not  more  than  the  one-twelfth  of  an 
inch   above   the   level   of    a   line   prolonged   horizontally 
backwards   from   the   upper   border   of    the  meatus.      It 
should  be  remembered  that  there  is  danger  of  woundino- 
the  labyrinth,  if  the  drill  be  allowed  to  penetrate  more 
than    three-quarters   of   an   inch   into    the   base   of    the 
mastoid  process."      The  position  of    the  lateral  sinus  is 
very   variable,   and   Professor  Thomson   has   collected   in 
the  Museum  of  the  Anatomical  Department  at  Oxford  a 
series  of  temporal  bones  from  children,  in  which  it  may 
be   seen   that   in   some  cases   it  would  be  impossible  to 
trephine  the  mastoid  bone  without  exposing  the    sinus. 


EXPLORATION    OF    MASTOID    PROCESS        3  I  I 

Neither  exposure  nor  pricking  of  the  lateral  sinus  adds 
materially  to  the  danger  of  the  operation,  though  of  course 
neither  accident  should  be  allowed  to  happen,  if  it  can 
possibly  be  avoided.  The  bleeding  from  a  small  puncture 
in  the  lateral  sinus  is  easily  arrested  by  pressure  with  a 
pad  of  lint. 

The  operation  of  trephining  is  considered  in  detail  on  page 
329.  It  is  here  sufficient  to  remember  that  the  presence 
of  pus  is  suspected  when  the  dura  mater  bulges  into  the 
trephine  hole,  and  when  no  cerebral  pulsation  can  be  felt. 
A  pair  of  sinus  forceps  should  be  introduced  into  the 
cerebral  substance  after  the  dura  mater  has  been  incised. 
Trocars  and  hollow  needles  are  useless  as  exploratory 
agents,  for  the  soft  brain  matter  blocks  them.  The  ab- 
scess cavity  may  be  gently  scraped,  and  if  the  pus  has 
been  very  foul  it  should  be  drained.  No  form  of  mer- 
curial dressing  or  lotion  should  be  employed,  as  mercurial 
salts  are  liable  to  form  stable  compounds  with  the 
cerebrum. 

Mr.  Ballance  says  that  a  trephine  opening  to  explore 
the  anterior  surface  of  the  petrous  bone,  the  roof  of  the 
tympanum,  and  the  petro-squamous  fissure,  has  its  centre 
situated  seven-eighths  of  an  inch  vertically  above  the 
middle  of  the  meatus,  i.e.  above  Reid's  base  lino.  The 
trephine  should  be  half  an  inch  in  diameter  for  an  adult. 
A  probe  passed  along  the  lower  margin  of  the  trephine 
hole,  after  the  crown  of  bone  has  been  removed,  can  be 
insinuated  between  the  dura  mater  and  the  bone,  so  as  to 
search  the  whole  of  the  anterior  surface  of  the  petrous 
portion  of  the  temporal  bone. 

Mr.  Barker  recommends  that  a  teinporo-sphenoidal 
abscess  should  bo  opened  with  a  half-inch  trephine,  situ- 
ated one  inch  and  a  quarter  behind,  and  one  inch  and  a 
quarter  above,  the  centre  of  the  external  auditory  meatus, 


312      THE    SURGICAL    DISEASES    OF    CHILDREN 

i.e.  above  Reid's  base  line ;  the  probe  being  directed  ,at 
first  inwards,  and  then  a  little  downwards  and  forwards. 

The  trephine-opening  for  a  cerebellar  abscess  should  be 
half  an  inch  in  diameter.  Its  centre  should  be  an  inch 
and  a  half  behind,  and  a  quarter  of  an  inch  below,  the 
centre  of  the  meatus.  Mr.  Ballance  says  that  the 
anterior  border  of  the  trephine  should  be  just  under 
cover  of  the  posterior  border  of  the  mastoid  process.  The 
aperture  in  the  skull  is  then  so  far  away  from  the  lateral 
sinus  that  any  instrument  introduced  into  the  substance 
of  the  brain  may  be  directed  forwards,  inwards  and 
upwards,  until  it  reaches  an  abscess  situated  in  the 
anterior  part  of  the  lateral  lobe  of  the  cerebellum,  which 
is  the  usual  site  of  collections  of  pus  in  this  part  of  the 
brain. 


CHAPTER  XVI 

INTRACRANIAL   DISEASE   AND   ITS 
SURGICAL   TREATMENT 

THROMBOSIS   OF   THE  CEREBRAL   SINUSES. 

Spontaneous  Thrombosis. 

Primary  thrombosis  is  occasionally  seen  in  the  longitu- 
dinal sinus,  and  in  the  tributary  veins  in  marasmic  children 
up  to  the  age  of  three  or  four  years.  It  does  not  appear  to 
give  rise  to  very  definite  symptoms,  for  the  children  are 
sleepy ;  but  there  is  no  evidence  of  any  meningitis.  There 
may  be  some  oedema  of  the  nasal  mucous  membrane,  with 
a  little  increased  fulness  at  the  root  of  the  nose.  They 
sometimes  moan  continuously.  Death  results  from  the 
constitutional  condition,  and  is  generally  preceded  by  coma. 
No  treatment  is  effectual. 

Infective  Thrombosis.31 

/Etiology. — Secondary  thrombosis  of  a  cerebral  sinus 
is  always  infective,  and  is  generally  pysemic  in  origin.  It 
is  most  frequently  associated  with  caries  or  necrosis  of  the 
posterior  wall  of  the  tympanum,  with  meningitis,  with 
cerebellar  abscess,  or  with  other  infective  lesions  of  the 
head  and  face.  A  purulent  pachymeningitis  is  set  up  in 
the  outer  wall  of  the  sinus,  and  this  leads  to  the  forma- 
tion of  a  purulent  thrombus.  The  cavernous  and  lateral 
sinuses,  as  well  as  the  upper  third  of  the  internal  jugu- 
lar  vein,  are   most  frequently  plugged,  and   often  by    a 

313 


314      THE    SURGICAL    DISEASES    OF    CHILDREN 

suppurating  clot.     Gangrene  of  the  lungs  may  result  from 
the  lodgment  of  infective  emboli. 

Symptoms. — The  symptoms  of  infective  thrombosis 
are  usually  sufficiently  well  marked  to  render  the  diag- 
nosis easy.  A  severe  pain  radiates  from  the  seat  of 
inflammation,  there  is  repeated  vomiting,  and  a  tempera- 
ture which  is  remarkable  for  its  rapid  rise,  and  for  its 
wide  and  irregular  oscillations.  Rigors  recur  at  definite 
intervals,  they  are  often  severe  and  very  prolonged.  The 
pulse  is  rapid,  small,  and  thready.  The  mastoid  region 
may  be  swollen  and  tender,  and  in  the  worst  cases  the 
swelling  extends  upwards  on  to  the  scalp,  and  downwards 
along  the  course  of  the  internal  jugular  vein,  which  may 
sometimes  be  felt  as  a  more  resistant  cord  in  the  neck.  The 
patient  complains  of  stiffness  in  the  muscles  at  the  back 
and  side  of  the  neck.  Optic  neuritis  in  varying  degrees 
of  severity  is  often  present,  and  there  may  be  some  facial 
paralysis.  The  intellectual  faculties,  at  first  benumbed, 
are  afterwards  abolished,  for  the  patient  loses  conscious- 
ness. Dyspnoea,  with  localised  pain  in  the  chest,  marks 
the  plugging  of  one  of  the  smaller  pulmonary  arteries, 
which  may  be  the  first  stage  towards  gangrene  of  the 
lung  and  the  death  of  the  patient. 

Diagnosis. — Although  the  symptoms  are  usually  so 
well  marked  that  no  mistake  can  be  made  in  the  diagnosis, 
yet  it  sometimes  happens  that  they  are  sufficiently 
obscure  to  prevent  its  recognition  even  by  those  who  are 
most  familiar  with  it.  The  following  case  shows  how 
easily  this  condition  may  be  overlooked,  owing  to  the  ill- 
development  of  the  symptoms,  even  when  one  is  on  the 
alert,  for  it  occurred  two  or  three  days  after  I  had  written 
the  above  account.  A  child,  aged  nineteen  months,  came 
under  my  care  to  be  treated  for  a  mastoid  abscess  in  June, 
1894.      Her  father  and  one  sister,  out  of  a  family  of  five, 


INTRACRANIAL    DISEASE  AND   ITS    TREATMENT    3  1  5 

were  dead  of  phthisis.  The  mastoid  bone  was  exposed, 
and  much  tuberculous  granulation  tissue  was  scraped 
away.  The  wound  soon  closed,  and  the  patient  was  dis- 
charged. A  month  later  she  was  re-admitted  to  the 
Victoria  Hospital,  suffering  from  diarrhoea.  She  vomited, 
but  beyond  screaming  she  gave  no  evidence  of  cerebral 
symptoms.  She  died  two  days  afterwards,  her  tempera- 
ture just  before  death  suddenly  rising  to  108°  F.  It  was 
found  at  the  autopsy  that,  in  addition  to  tuberculous 
disease  of  the  viscera,  she  bad  a  clot  in  the  left  lateral 
sinus,  with  such  extensive  necrosis  of  the  petrous  portion 
of  the  right  temporal  bone,  that  a  round  sequestrum  as 
large  as  a  sixpence  lay  loose  in  the  brain  case. 

Secondary  thrombosis  may  also  be  mistaken  for  an 
attack  of  typhoid  fever,  from  which  it  may  be  distinguished 
by  the  repeated  rigors  and  by  the  oscillating  temperattvre 
marking  the  pysemic  condition. 

An  acute  inflammation  of  the  middle  ear,  leading  to 
the  formation  of  an  abscess  which  bursts  through  the 
mastoid  and  tracks  down  the  neck,  is  liable  to  be  mis- 
taken for  secondary  thrombosis,  but  the  swelling  is  situ- 
ated farther  back  in  the  neck,  and  the  jugular  vein 
remains  unaffected.  In  such  cases  the  patient  is  con- 
scious, and  although  there  may  be  severe  rigors,  the 
temperature  is  not  so  high  in  the  intervals. 

Prognosis. — The  prognosis  is  always  serious,  and  in 
cases  where  thrombosis  of  the  lateral  sinus  is  suspected, 
and  the  mastoid  vein  is  plugged,  the  sinus  should  be  ex- 
plored at  once  ;  for  only  in  very  exceptional  cases  does 
the  abscess  burst  and  discharge  immediately  through  the 
mastoid,  or  mediately  through  the  antrum. 

Treatment. — The  internal  jugular  vein  should  first 
be  expose  I  in  the  neck,  ligatured  below  the  thrombus, 
and  it  should  then  be  divided,  for  this  will  prevent  the 


J 


1 6      THE    SURGICAL    DISEASES    OF    CHILDREN 


extension  of  the  thrombosis,  and  will  lessen  the  risk  of 
embolism  occurring  during  the  operation  from  interference 
with  the  clot.  The  blocked  portion  of  the  vein  may  be 
opened  and  irrigated  if  necessary.  A  pad  of  antiseptic 
gauze  is  then  placed  over  the  wound,  or  it  may  be  closed 
at  once. 

The  lateral  sinus  is  then  explored  by  trephining  over  it. 
This  should  be  done  by  turning  down  a  flap  of  soft  tissues, 
including  the  pericranium,  one  point  of  the  semicircle  com- 
mencing immediately  behind  and  just  above  the  ear,  and 
being  carried  backwards  for  a  sufficient  distance  to  enable 
a  1-inch  trephine  to  be  worked  with  ease.  The  lateral 
sinus  (fig.  35)  runs  from  just  below  the  inion,  or  external 
occipital  protuberance,  horizontally  round  the  skull  until 
it  reaches  the  parieto-occipital  suture.  It  here  makes  a 
sharj)  turn  downwards  on  to  the  temporal  bone.  The 
mastoid  vein  or  veins  open  obliquely  into  this  descending 
part  of  the  sinus,  which  again  curves  forwards  out  of  the 
reach  of  surgical  interference.  If  the  pin  of  the  trephine 
be  placed  over  the  skull  at  the  point  where  the  mastoid 
vein  enters,  there  will  be  no  difficulty  in  exposing  the 
sinus,  for  the  vein  opens  directly  into  it  and  passes 
through  the  skull  on  a  level  with  it.  Mr.  Ballance  states 
that  in  an  adult  the  trephine  opening  to  expose  the 
lateral  sinus  should  have  its  centre  one  inch  behind,  and  a 
quarter  of  an  inch  above,  the  middle  of  the  bony  meatus, 
i.e.  above  Reid's  base  line ;  but  in  the  child's  skull  from 
which  my  figure  was  drawn,  it  was  necessary  to  place  the 
pin  of  the  trephine  upon  the  base  line,  as  is  seen  in  fig. 
35  D.  A  trephine  is  used  measuring  five-eighths  of  an 
inch  in  diameter,  and  the  opening  in  the  bone  should 
be  extended  forwards  with  a  gouge  or  cutting  forceps, 
so  as  to  open  up  the  mastoid  cells.  The  sinus  is  care- 
fully laid  open   as  soon  as  the  crown  of  bone  has  been 


INTRACRANIAL    DISEASE  AND  ITS    TREATMENT    3  I  7 

removed.  Its  cavity  is  cleared,  and  rendered  as  aseptic 
as  possible  by  flushing  it  with  a  solution  of  perchloride 
of  mercury  1  in  2000,  at  a  temperature  of  105°  F.  The 
wound  is  then  freely  drained,  and  both  it  and  the  one 
in  the  neck  are  dressed  antiseptically. 

Death  in  untreated  cases  usually  takes  place  within 
three  weeks,  from  gangrene  of  the  lung  or  from  general 
pj'aemia. 

CEREBRAL  MENINGITIS. 

^Etiology. — Inflammation  of  the  cerebral  meninges  is 
always  infective  in  origin.  It  is  either  simple  or  suppu- 
rative, primary  or  secondary.  Idiopathic  suppurative 
meningitis  may  occur  from  many  causes,  the  most 
frequent  being  tubercle.  Recent  researches  show  that  it 
may  be  produced  as  a  primary  or  secondary  affection  by 
pneumococci,  streptococci,  staphylococci,  and  the  bacillus 
coli.  The  meninges  of  the  brain  are  directly  involved 
in  the  primary  affection  without  the  production  of  any 
general  disease,  such  as  typhoid  fever,  pneumonia,  ab- 
scesses, or  furunculosis.  Secondary  meningitis,  on  the 
other  hand,  occurs  in  the  course  of  one  of  these  general 
diseases,  in  endocarditis,  in  influenza,  or,  it  may  be,  after 
a  compound  fracture  of  the  skull. 

NOX-TlJBERCULOUS   MENINGITIS.32 

These  forms,  of  non-tuberculous  meningitis  are  therefore 
either  pyogenic  or  non-pyogenic  in  origin.  They  usually 
affect  the  convex  surface  of  the  pia  mater,  and  they  are 
generally  bilateral,  although  if  they  originate  from  a 
specific  focus,  as  from  a  fracture,  or  from  middle  ear  disease, 
the  inflammation  may  be  confined  to  one  hemisphere.  The 
special  form  produced  by  pneumococci  is  said  to  be  nearly 
always  cerebro-spinal,  and  it  is  perhaps  the  cause  of  the 
epidemic    cerebro-spinal    meningitis,    which    occasionally 


J 


1 8      THE    SURGICAL    DISEASES    OF    CHILDREN 


sweeps  over  countries  with  the  devastating  effects  of  a 
plague.  The  effusion  is  often  very  abundant ;  it  is  thick 
and  plastic  in  character,  and  may  be  of  a  characteristic 
green  colour,  with  a  peculiar  sickly  smell ;  but  in  other 
cases  it  is  thin  and  serous,  and  has  less  characteristic 
properties.  The  inflammation  spreads  by  means  of  the 
lymphatic  system,  and  the  micro-organisms  may  often  be 
found  in  the  peri-arterial  lymphatic  vessels. 

Symptoms. — The  symptoms  sometimes  set  in  with 
startling  rapidity,  and  this  absence  of  a  prodromal  period 
distinguishes  the  less  common  forms  of  infective  menin- 
gitis from  that  produced  by  tubercle. 

There  is  a  short  stage  of  excitement,  with  a  temperature 
of  103-4°  F.,  headache,  vomiting  without  nausea,  con- 
stipation, and  inequality  of  the  pupils.  The  pulse  varies 
greatly  during  the  attack:  at  one  time  it  is  quick,  at 
another  time  slow;  at  one  time  regular,  and  at  another 
intermittent.  There  is  delirium  later  in  the  disease, 
followed  by  convulsions,  retraction  of  the  head  and  belly, 
due  to  tonic  contractions  of  the  muscles,  with  paralysis  of 
one  or  more  of  the  cranial  nerves,  and  more  or  less  hemi- 
plegia. These  symptoms  terminate  in  coma,  Cheyne- 
Stokes'  breathing,  relaxation  of  the  sphincters,  dilatation 
of  the  pupil,  and  death.  The  disease  usually  runs  an 
acute  course,  but  it  is  sometimes  subacute  or  chronic. 

Diagnosis.— The  diagnosis  is  difficult,  for  all  these 
symptoms  may  be  present,  and  yet  at  the  autopsy  no 
meningitis  can  be  discovered.  The  non-tuberculous  men- 
ingitis has  to  be  distinguished  from  the  much  more 
common  tuberculous  form.  Dr.  Gee  and  Dr.  Barlow 
believe  that  cervical  opisthotonus  is  an  essential  sign  of 
non-tuberculous  basal  meningitis,  whilst  in  the  tuberculous 
form  it  is  an  accidental  symptom.  It  is  a  tonic  contrac- 
tion, and  becomes  more  pronounced  as  the  patient  is  raised 


INTRACRANIAL    DISEASE  AND  ITS    TREATMENT    319 

into  an  erect  position.  It  is,  however,  inconstant,  and 
may  be  absent  entirely,  or  being  present,  it  may  disappear 
whilst  the  inflammation  still  progresses. 

Prognosis. — Recovery  may  take  place  spontaneously, 
or  after  an  operation  to  relieve  the  intracranial  pressure 
by  providing  an  exit  for  the  cerebro-spinal  fluid.  Death, 
however,  is  by  far  the  most  frequent  ending. 

Treatment. — The  indication  for  the  palliative  treat- 
ment of  these  cases  is  to  get  rid  of  the  source  of  infection 
if  it  be  possible.  This  is  best  done  by  disinfecting  the 
alimentary  canal.  The  mouth  must  be  frequently  washed 
out  with  a  saturated  solution  of  creolin,  whilst  /8-naphthol 
is  given  every  three  hours,  in  one-grain  doses  admin- 
istered in  milk,  or  one  and  a  half  to  three  grains  of 
naphthaline  as  a  powder,  if  it  be  preferred. 

The  operative  treatment  consists  in  trephining  (p.  329) 
the  skull  when  it  is  possible  to  localise  the  inflammation, 
or  if  there  is  evidence  of  acute  distension  of  the  ventricles. 
The  operation,  therefore,  should  always  be  performed 
when  the  inflammation  is  associated  with  a  fractured 
skull,  and  when  hemiplegia  supervenes  after  a  trivial 
injury  to  the  scalp,  even  though  the  symptoms  do  not 
come  on  for  five  or  six  weeks. 

Tuberculous  Meningitis. 

etiology. — Tuberculous  disease  of  the  brain  and  its 
membranes  is  usually  secondary  to  tuberculous  disease  of 
the  thoracic  and  abdominal  organs,  and  of  the  mesenteric 
glands,  even  though  the  cerebral  symptoms  do  not  appear 
until  the  primary  disease  is  cured.  It  may  originate  in  a 
tuberculous  inflammation  of  the  middle  ear ;  much  more 
rarely  it  is  in  connection  with  tuberculous  joints,  bones, 
or  superficial  lymphatic  glands.  In  a  few  instances  it 
seems  to  be  truly  primary  in  origin. 


320      THE    SURGICAL    DISEASES    OF    CHILDREN 

Pathology. — The  pia  mater  at  the  base  of  the  brain  is 
chiefly  affected.  Miliary  tubercles  are  also  found  along 
the  fissure  of  Sylvius  and  in  the  velum  interpositum.  The 
latter,  by  the  inflammation  to  which  they  give  rise,  lead 
to  blocking  of  the  venae  Graleni,  and  so  to  a  vascular 
disturbance,  causing  distension  of  the  ventricles  with 
cerebro-spinal  fluid.  This  produces  such  cerebral  com- 
pression as  to  cause  death.  Caseating  masses  are  often 
found  in  the  substance  of  the  cerebellum,  and  even  of 
the'  cerebrum  in  these  cases.  The  masses  appear  to  have 
been  long  antecedent  to  the  meningeal  inflammation,  for 
they  are  sometimes  calcified.  They  rarely  give  rise  to 
symptoms. 

Symptoms. — Prodromal  symptoms  are  more  frequent 
in  tuberculous  meningitis  than  in  the  non-tuberculous 
forms.  They  are  often  trivial.  A  little  increase  in  the 
child's  irritability,  listlessness,  slight  frontal  headache,  an 
exaltation  of  cutaneous  sensibility,  a  few  attacks  of  sudden 
vomiting,  and  a  slight  but  intermittent  squint,  may  be  the 
sole  indications  of  the  deadly  process  going  on  within  the 
skull.  The  temperature  is  only  slightly  raised  at  first, 
for  it  is  often  not  more  than  99°-100°  F.  More  acute 
symptoms  manifest  themselves  after  a  period  of  days,  or 
weeks,  or  months.  There  is  sudden  and  repeated  vomiting, 
with  an  agonising  headache,  often  paroxysmal,  and  accom- 
panied with  the  peculiar  piercing  shriek  which  used  to  be 
described  as  the  "  hydrocephalic  cry."  The  hyperaesthesia 
becomes  more  marked,  slight  sounds  annoy  the  child,  there 
is  photophobia,  and  the  pupils  are  contracted.  A  marked 
remission  often  takes  place  in  these  cases,  but  the  im- 
provement is  nearly  always  delusive.  Sooner  or  later  the 
pupils  dilate,  the  temperature  rises  and  becomes  remark- 
ably variable,  the  pulse  becomes  irregular,  there  is  Cheyne- 
Stokes'  respiration.     General  or  partial  convulsions  take 


INTRACRANIAL    DISEASE  AND  ITS    TREATMENT    32 1 

place  ;  but  soon  the  coma  deepens,  the  paralysis  becomes 
more  and  more  marked,  there  is  loss  of  control  over  the 
sphincters,  the  temperature  rises  rapidly,  and  the  child 
dies. 

Diagnosis. — Tuberculous  meningitis  has  to  be  distin- 
guished from  the  other  forms  of  infective  cerebral  inflam- 
mation, as  well  as  from  the  pressure  effects  caused  by 
injury  and  tumours.  The  tuberculous  inflammation  is  so 
common  in  children,  and  other  evidence  of  tuberculous 
disease  is  so  easily  obtained,  that  there  is  rarely  any  diffi- 
culty in  distinguishing  this  form  of  meningitis.  The  history 
of  hereditary  tubercle,  the  gradual  onset,  the  rapid  loss  of 
flesh,  and  the  irregular  temperature,  go  far  to  verify  the 
diagnosis.  Too  much  reliance  must  not  be  placed  upon 
the  results  of  ophthalmoscopic  examination,  for  many 
cases  of  tuberculous  meningitis  run  their  course  without 
giving  rise  to  visible  intraocular  changes.  The  surgeon 
must  be  constantly  on  his  guard ;  for  although  the  diag- 
nosis of  tuberculous  meningitis  is  usually  easy,  he  should 
remember  that  few  diseases  assume  so  protean  a  form, 
and  in  few  is  the  course  so  often  atypical.  The  diag- 
nosis, however,  may  be  rendered  absolute  by  finding 
tubercle  bacilli  in  the  cerebro-spinal  fluid  obtained  by 
puncture  of  the  vertebral  canal  in  the  lumbar  region  in 
the  manner  described  on  page  322. 

Prognosis. — Death  is  so  certain  in  these  cases  that 
the  treatment  of  tuberculous  meningitis  can  only  be  con- 
sidered palliative. 

Treatment. — The  cause  of  death  appears  to  be  the  in- 
tracranial pressure,  often  exaggerated  by  the  vascular  dis- 
turbance caused  by  venous  obstruction.  Trephining  the 
skull  has  therefore  often  been  practised  for  its  relief.  One 
case  which  fell  under  my  immediate  observation  was,  I 
believe,  cured  by  the  operation. 

Y 


32  2      THE    SURGICAL    DISEASES    OF    CHILDREN 

A  girl,  aged  five,  suffering  from  all  the  symptoms  of 
tuberculous  meningitis,  appeared  to  be  rapidly  passing  into 
the  stage  of  coma,  with  paralysis.  It  was  therefore  deter- 
mined to  drain  the  subarachnoid  space  as  low  as  possible. 
The  trephine  was  placed  upon  the  left  side  of  the  skull, 
halfway  between  the  occipital  crest  and  the  mastoid  pro- 
cess. The  dura  mater  bulged  forwards  as  soon  as  the 
crown  of  bone  was  removed.  It  was  incised,  and  a  few 
drops  of  cerebro-spinal  fluid  escaped.  The  cerebellum  im- 
mediately filled  the  trephine  hole,  and  prevented  the  escape 
of  more  fluid.  A  silver  probe  passed  inwards  towards  the 
falx,  between  the  cerebellum  and  the  arachnoid,  allowed 
several  drachms  of  serous  fluid  to  escape.  A  drainage- 
tube  was  then  passed  along  the  probe,  and  was  left  lying 
between  the  brain  and  its  membrane,  and  the  dura  mater 
was  replaced.  The  crown  of  bone,  which  had  been  kept 
in  warm  boric  solution,  was  broken  up,  the  fragments  were 
placed  over  the  dura  mater,  and  the  wound  was  closed. 
A  free  discharge  of  cerebro-spinal  fluid  occurred  for  a  week 
after  the  operation.  The  child  rallied  well,  and  immedi- 
ately began  to  improve.  She  was  eventually  discharged, 
and  she  has  since  paid  many  visits  to  the  hospital.  The 
case,  which  was  under  the  care  of  my  colleagues,  Dr.  Ord 
and  Mr.  Waterhouse,  is  recorded  in  detail  in  the  Trans- 
actions of  the  Medical  Society  for  1894.  I  have  since  re- 
peated the  operation  several  times,  and  with  temporary 
relief ;  but  no  other  case  has  been  cured. 

Puncture  of  the  Vertebral  Canal.33 

Ziemssen  in  Munich  and  Dr.  Essex  Wynter  in  London 
have  recently  advocated  puncture  of  the  vertebral  canal 
and  evacuation  of  the  cerebro-spinal  fluid  in  cases  of  tuber- 
culous meningitis.  Quincke  has  shown  by  dissection  that 
in  children  of  one  year  old  the  spinal  cord  reaches  to  the 


INTRACRANIAL    DISEASE  AND  ITS    TREATMENT    323 

second  lumbar  vertebra,  whilst  in  the  newly  born  child  it 
extends  to  the  third,  and  he  has  advised  a  similar  punc- 
ture for  the  relief  of  hydrocephalus. 

The  child  is  held  in  a  sitting  position,  with  his  back 
turned  towards  the  surgeon.  He  is  then  bent  forward  to 
make  the  space  between  the  vertebral  arches  as  large  as 
possible.  A  minute  incision  is  made  through  the  skin 
between  the  third  and  fourth  lumbar  vertebrae,  and  just  to 
one  side  of  the  spinous  process.  A  very  fine  trocar  and 
canula,  which  have  been  freshly  boiled,  is  then  pushed  in 
through  the  skin  incision  until  it  impinges  upon  the 
lamina,  when  its  point  is  directed  somewhat  downwards, 
and  it  is  driven  through  the  ligamentum  subflavum  and 
the  theca  towards  the  middle  line  for  a  distance  of  a  little 
less  than  an  inch.  The  trocar  is  withdrawn  whilst  the 
canula  is  left  in  place,  and  clear  cerebro-spinal  fluid  at 
once  escapes.  The  nerve  roots  forming  the  cauda  equina 
in  young  children  are  usually  collected  into  two  compact 
bundles  lying  upon  either  side  of  the  vertebral  canal,  so 
that  there  is  very  little  danger  of  injuring  them. 

The  surgeons  who  have  used  this  method  most  exten- 
sively report  favourably  upon  it,  for  they  all  agree  that 
temporary  relief  is  obtained  which  might  be  permanent  if 
it  were  possible  to  establish  a  fistula  through  which  the 
cerebro-spinal  fluid  escaped  constantly.  The  operation  is  a 
trivial  one  if  everything  is  kept  aseptic,  and  it  appears  to 
be  well  worthy  of  a  more  extensive  trial,  as  it  is  of  great 
diagnostic  value.  Hirschberg  objects  to  the  method,  on  the 
ground  that  it  is  impossible  to  drain  the  skull  through  the 
vertebral  canal  under  the  conditions  which  are  present  in 
tuberculous  meningitis.  The  objection  is  a  theoretical  one, 
and  it  has  yet  to  be  proved  whether  it  is  founded  on  a 
basis  of  fact.  He  prefers,  like  many  other  surgeons,  the 
operation  of  trephining  for  the  relief  of  these  cases. 


324      THE    SURGICAL    DISEASES    OF    CHILDREN 

Trephining. 
The  cases  of  meningitis  to  be  trephined  or  punctured 
must  be  selected  with  care.  Those  which  are  associated 
with  active  tuberculous  mischief  in  the  viscera  or  other 
organs  are  unfitted  for  operative  interference,  as  there  is 
a  constant  source  of  infection.  The  later  stages  of  the 
disease  are  also  unsuitable.  Good  results  may  perhaps 
be  obtained  when  the  case  is  seen  early ;  when  the  men- 
ingitis is  primary  in  origin  ;  when  it  follows  an  attack  of 
pleurisy  or  peritonitis,  from  which  complete  recovery  has 
taken  place  ;  when  it  is  associated  with  tuberculous  lym- 
phatic glands  which  can  be  removed  without  danger ;  when 
it  is  in  connection  with  an  otorrhoea  amenable  to  surgical 
treatment ;  and  when  it  is  due  to  such  local  causes  as 
fracture,  leading  either  primarily  or  secondarily  to  the 
formation  of  a  cerebral  abscess.  The  same  pathological 
reasoning  which  leads  us  to  open  the  peritoneal  cavity  in 
cases  of  tuberculous  peritonitis  leads  us  to  evacuate  the 
fluid  in  cases  of  tuberculous  meningitis  ;  but  both  opera- 
tions are  still  in  a  state  of  probation. 

THE  CEREBRO-CRANIAL  TOPOGRAPHY  IN 
CHILDREN.34 

The  cranio-cerebral  topography  in  children  has  been 
carefully  worked  out  by  Eouillehouze  (fig.  34),  whose 
results  have  been  verified  and  accepted  by  Dana.  The 
differences  in  the  adult  (fig.  33)  and  in  the  child  (fig.  34) 
are  not  great.  The  chief  points  of  importance  are  that  the 
bregma  in  the  child  lies  close  to  the  posterior  edge  of  the 
anterior  fontanelle.  The  upper  end  of  the  fissure  of  Rolando 
is  situated  either  at,  or  a  little  in  front  of,  its  position  in 
the  adult,  for  its  upper  end  during  the  first  months  of  life 
is  from  30  to  35  mm.  behind  the  bregma,  the  antero- 
posterior diameter  of   the  brain  being   113*5  mm.      It  is 


INTRACRANIAL    DISEASE  AND  ITS    TREATMENT    325 

42-43  mm.  behind  the  bregma  during  the  second  to  third 
year,  and  after  this  age  it  rapidly  assumes  the  same  rela- 
tions as  in  the  adult.  The  lower  end  of  the  fissure  is  pro- 
portionately higher  until  the  third  year,  after  which  it  falls 
to  the  adult  position.  The  fissure  is  therefore  situated  some- 
what higher  up  and  a  little  farther  back  in  children  than 
in  adults.  The  fissure  of  Sylvius  is  a  little  more  oblique  in 
children  up  to  the  third  or  fourth  year,  and  lies  higher  above 
the  squamous  suture  than  in  adults.  Its  posterior  branch 
lies  either  just  under  the  squamous  suture  at  its  highest 
point,  or  ^  to  1  cm.  above  it.  It  runs  up  to,  and  usually 
above  and  in  front  of,  the  parietal  eminence,  i.e.  the  parietal 
eminence  in  children  is  relatively  lower  than  in  adults. 

The  parieto-occipital  fissure  is  either  exactly  under  the 
lambda  or  1  to  2  cm.  in  front  of  it. 

Exploration  of  the  Cerebral  Ventricles.35 — The  operation 
of  draining  the  ventricles  has  been  performed  for  compound 
fracture  of  the  skull  with  secondary  implication  of  the 
ventricles,  and  for  the  relief  of  acute  hydrocephalus.  It 
is  useless  in  chronic  cases.  The  operation  was  first  pro- 
posed by  Wernicke  in  1881,  though  puncture  of  the  brain 
for  the  relief  of  hydrocephalus  dates  back  to  the  time 
when  Stevens  proposed  that  it  should  be  employed  in  the 
case  of  Dean  Swift  in  1744.  It  was  first  carried  out  by 
Zenner,  of  Cincinnati,  in  1886.  It  has  since  been  elabo- 
rated by  Keen  in  -America,  and  by  Broca  in  France.  It 
appears  to  be  more  satisfactory  to  drain  the  ventricles 
laterally  than  either  through  the  anterior  or  the  posterior 
horns.  Keen  gives  the  following  directions  for  finding  the 
different  parts  of  the  lateral  ventricle  in  the  adult ;  and  so 
far  as  I  have  proved  them  in  children,  they  are  sufficiently 
correct  for  all  practical  purposes. 

(1)  Trephine  (fig.  35  b)  halfway  between  the  external 
occipital  protuberance  and  the  upper  end  of  the  fissure  of 


26      THE    SURGICAL    DISEASES    OF    CHILDREN 


Rolando,  at  a  distance  of  \  to  f  inch  to  either  side  of 
the  middle  line.  Puncture  towards  the  inner  edge  of  the 
supraorbital  ridge  of  the  same  side.  The  puncture  will 
pass  through  the  precuneus,  and  the  normal  ventricle  will 
be  struck  at  some  point  in  the  posterior  horn  at  a  depth 


Fig.  33.— Skull  showing  the  position  of  the  chief  cerebral  fissures  in  the 
adult  (cf.  fig.  34)  with  Reid's  base-line.  A,  Glabella;  B, external  occipital  pro- 
tuberance ;  e.a.p.,  external  angular  process  of  the  frontal ;  B,  C,  transverse 
fissure;  Sy.  fis.,  fissure  of  Sylvius;  Sy.  h.  fis.,  horizontal  limb  of  the  fissure 
of  Sylvius ;  Sy.  a.  fis.,  ascending  limb  of  the  fissure  of  Sylvius ;  I),  E,  perpen- 
dicular line  from  depression  in  front  of  external  auditory  meatus  to  middle 
line  of  top  of  head;  F,  G,  perpendicular  line  from  posterior  end  of  base  of 
mastoid  process  to  middle  line  of  top  of  head  ;  F,  H,  fissure  of  Rolando;  p.  o. 
fis.,  parieto-occipital  fissure;  +  most  prominent  part  of  parietal  eminence. 
(Copied  by  permission  of  Prof.  Reid  from  the  Lancet,  vol.  ii.,  1884,  p.  639.) 


of  21  to  2|  inches  from  the  surface  of  the  scalp, 
method  gives  the  best  drainage. 


This 


INTRACRANIAL    DISEASE  AND    ITS    TREATMENT    327 


(2)  Measure  the  distance  from  the  glabella  to  the  upper 
end  of  the  fissure  of  Rolando — a  distance  of  about  6  inches 
in  a  child  aged  two  years.  Trephine  at  the  junction  of 
the  anterior  and  middle  third  of  this  line  and  h  to  £  inch 
away  from  the  middle  line  of  the  skull  (fig.  35  a).  The 
puncture  will  traverse  the  first  frontal  convolution  well  in 
front  of  the  motor  zone,  and  the  normal  ventricle  will  be 
struck  in  the  anterior  horn  at  about  2  to  2\  inches  below 


B  re  cm  a 


Par/elo 


G/acie/'a 


Fig.  3t.— Outline  drawn  from  the  skull  of  a  child,  aged  about  three  years,  to 
illustrate  the  main  points  in  the  cranio-cerebral  topography  of  children.  The 
position  of  the  lambda  and  inion  are  only  approximate,  as  they  cannot  be 
seen  in  a  side  view.  The  skull  is  tilted  laterally  to  show  the  sagittal  suture. 
Its  antero-posterior  measurement  from  the  glabella  to  the  inion  was  287"5  mm. 

the  scalp.  The  objection  to  this  method  is  the  real  one, 
that  it  leaves  a  scar  on  the  forehead ;  and  the  theoretical 
one,  that  injury  might  be  done  to  the  corpus  striatum.  It 
is  serviceable,  however,  in  a  compound  fracture  of  the 
skull,  when  there  is  reason  to  believe  that  the  ventricle  is 
distended  with  blood. 

(3)    Trephine   1\   inch  behind  the  posterior  margin  of 


328      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  external  auditory  meatus  and  1|  inch  above  Reid's 
base-line  (fig.  35  c),  i.e.  a  line  drawn  backward  from  the 
inferior  border  of  the  orbit  through  the  middle  of  the  ex- 
ternal auditory  meatus  to  the  occiput.  Puncture  towards 
a  point  just  above  the  external  auditory  meatus  of  the 
opposite  side.  The  puncture  will  traverse  the  second 
temporo-sphenoidal  convolution,  and  will  enter  the  normal 
lateral  ventricle  at  the  beginning  or  in  the  course  of  the 
descending  cornu  at  a  depth  of  about  2  to  2\  inches  from  the 


Fig.  35. — Outline  drawn  from  the  skull  of  a  child,  aged  about  three  years. 
It  shows  Reid's  base-line  passing  through  the  centre  of  the  external  auditory 
meatus,  and  the  curved  outline  of  the  lateral  sinus.  A,  denotes  the  point  at 
■which  to  trephine  for  the  purpose  of  exploring  the  right  lateral  ventricle 
through  its  anterior  horn  ;  B,  point  to  trephine  for  exploring  the  right  lateral 
ventricle  through  its  posterior  horn;  C,  point  to  trephine  for  exploring  the 
right  lateral  ventricle  through  its  lateral  horn ;  D,  point  to  trephine  for  explor- 
ing the  lateral  sinus  in  cases  of  infective  thrombosis. 

surface.  This  is  the  method  best  suited  to  ordinary  cases, 
as  it  allows  a  temporo-sphenoidal  abscess  to  be  dealt  with, 
if  it  be  found  in  the  course  of  the  operation  that  an  error 
has  been  made  in  the  diagnosis. 


INTRACRANIAL    DISEASE  AND    ITS   TREATMENT    329 

Trephining  is  neither  a  difficult  nor  a  dangerous  opera- 
tion. The  head  must  be  shaved  and  thoroughly  cleansed 
overnight,  and  an  antiseptic  dressing  should  be  applied  until 
the  time  of  the  operation.  The  surgeon,  having  selected 
the  point  at  which  he  proposes  to  trephine,  makes  a  semi- 
circular flap,  cutting  down  to  the  bone.  The  convexity  of 
the  incision  is  directed  upwards,  as  there  is  less  haemor- 
rhage, owing  to  the  arteries  being  divided  farther  away 
from  their  origins.  As  soon  as  the  bone  is  exposed,  the 
surgeon  places  the  pin  of  a  f-inch  trephine  at  the  point 
where  he  desires  to  expose  the  meninges.  He  works  his 
trephine  with  care  until  a  good  groove  is  formed  in  the 
bone,  when  the  centre-pin  is  withdrawn  or,  better  still, 
is  removed.  Great  care  must  be  taken  to  divide  the 
bone  evenly  at  each  part  of  its  circumference,  or  the  dura 
mater  may  be  lacerated.  The  application  of  a  thin  raspa- 
tory or  periosteal  elevator  will  enable  the  crown  of  bone  to 
be  removed  easily  when  it  has  been  cut  through.  If  the 
dura  mater  is  tense,  elastic,  and  does  not  pulsate,  it  may  be 
assumed  that  the  ventricles  are  distended.  The  dura  mater 
should  be  incised  in  such  cases,  and  the  brain  explored 
with  a  grooved  director.  The  clear  fluid  readily  flows  out, 
and  with  considerable  force,  if  the  ventricles  be  distended. 
The  rapid  evacuation  of  fluid  from  the  ventricles  does  not 
seem  to  be  attended  with  any  evil  results,  and  quite  re- 
cently I  removed  two  and  a  half  ounces  from  one  ventricle 
with  marked  temporary  improvement  in  the  pulse  and 
respiration.  The  ventricles  may  be  drained  through  the 
brain  by  inserting  into  them  a  drainage-tube  of  stout  rub- 
ber, or,  better  still,  by  a  small  bundle  of  horsehairs,  for 
the  tube  is  apt  to  get  clogged.  The  wound  is  then  closed 
with  point  sutures,  and  antiseptic  dressings  aro  applied. 
I  do  not  consider  it  necessary  to  replace  the  crown  of  bone 
either  wholly  or  in  fragments,  for  trephine  holes  in  children 


33°      THE    SURGICAL    DISEASES    OF    CHILDREN 


soon  begin  to  dimmish  in  size.  It  is  better  not  to  use  mer- 
curial  dressings  and  lotions  in  these  cases,  as  there  is  a 
theoretical  objection  that  they  may  form  stable  salts  with 
the  brain  substance. 

CEREBRAL  TUMOURS. 

Intracranial  tuberculous  disease  takes  two  forms.  It 
either  occurs  as  a  tumour  embedded  in  the  cerebral  sub- 
stance, or  as  a  miliary  tuberculosis  of  the  membranes. 
The  two  forms  are  only  combined  in  a  few  cases.  The 
symptoms  of  embedded  tumours  are  usually  marked  by  an 
absence  of  fits,  paralysis,  or  sickness.  There  may  be  im- 
paired vision  due  to  optic  neuritis,  and  drowsiness  is  often 
a  very  marked  symptom.  These  cases  of  tuberculous  dis- 
ease, however,  are  unfitted  for  surgical  operation,  as  the 
tumours  are  large,  often  deeply  seated  and  caseating ;  so 
that  they  could  not  be  completely  removed.  Dr.  Peterson 
estimates  that  25  per  cent,  of  the  tumours  occurring  in 
the  brains  of  children  are  tuberculous.  Gliomata  and  sar- 
comata form  nearly  all  the  rest.  None  of  these  growths 
lend  themselves  readily  to  operative  treatment  under  pre- 
sent conditions,  so  that  the  surgical  treatment  of  cerebral 
tumours  in  children  as  yet  hardly  exists. 

CHRONIC  HYDROCEPHALUS. 

A  considerable  number  of  these  cases  constantly  come 
under  the  notice  of  the  surgeon  to  a  children's  hospital. 

Treatment.  —  My  own  routine  practice  in  the  more 
severe  cases  is  to  draw  off  the  fluid  from  the  lateral  ven- 
tricles by  puncturing  at  the  outer  angle  of  the  anterior 
fontanelle  with  a  fine  and  thoroughly  aseptic  trocar  and 
canula.  The  instrument  should  be  directed  outwards  and 
a  little  backwards.  It  is,  I  think,  better  to  remove  the 
fluid  by  repeated  punctures  than  to  run  the  risk  of  setting 


INTRACRANIAL   DISEASE    AND   ITS    TREATMENT    33 1 

up  cerebral  symptoms  by  withdrawing  the  whole  of  it  at 
one  time ;  for  the  intracranial  conditions  here  are  very 
different  from  those  in  acute  distension  of  the  ventricles. 
The  child  is  to  be  properly  prepared  overnight  by  having 
his  head  shaved,  cleansed,  and  bandaged,  as  though  he 
were  to  undergo  a  serious  operation.  The  skin  should  be 
divided  with  a  scalpel,  to  prevent  any  particle  of  unclean 
epithelium  being  carried  into  the  ventricles  on  the  end  of 
the  trocar.  A  piece  of  cotton-wool  soaked  in  collodion  is 
sufficient  to  close  the  wound  when  the  operation  is  com- 
pleted. The  operation  is  useless  in  children  whose  skulls 
are  firmly  consolidated. 

The  Treatment  of  Microcephalus  and  Idiocy. 

The  operation  of  craniotomy  in  all  its  forms  for  the  treat- 
ment of  microcephalus  and  idiocy  has  proved  so  unsuccess- 
ful and  so  dangerous  in  all  the  cases  which  I  have  had  an 
opportunity  of  observing,  that  I  do  not  consider  it  a  legiti- 
mate surgical  procedure.  The  excellent  results  obtained 
by  a  judicious  process  of  education  show  how  much  can 
be  done  to  ameliorate  the  condition  of  these  unfortunate 
children. 

Treatment  of  Meningo-Encephalocele. 
There  is  no  reason  why  these  cases  of  pulsating  tumour 
springing  from  the  site  of  a  fontanelle  should  not,  in  the 
case  of  healthy  children,  be  removed  by  the  ordinary  aseptic 
methods.  Care  must  of  course  be  taken  that  the  wound 
should  heal  by  first  intention,  and  that  an  aseptic  liga- 
ture be  placed  round  the  sac.  Several  successful  cases' are 
recorded.  The  operation  may  be  done  in  two  stages  :  the 
first  to  draw  off  the  fluid,  and  the  second  to  remove  the 
brain  substance  if  it  cannot  be  kept  in  place  by  a  pad  and 
bandage,  or  other  form  of  truss. 


CHAPTER   XVII 
SURaiCAL  DISEASES  OF  THE  AIR  PASSAGES 

DIPHTHERIA  IN  ITS  SURGICAL  ASPECTS. 

Pathology.  —  Scientific  inquirers  have  now  satisfied 
themselves  that  diphtheria,  like  many  other  infective 
diseases,  is  really  of  several  types.  The  simplest  but  most 
virulent  is  associated  with  the  presence  of  a  specific  or- 
ganism known  as  the  Klebs-Loffler  bacillus,  whilst  the 
more  common  type  is  due  to  a  mixture  of  this  bacillus 
with  many  forms  of  septic  organisms. 

The  Klebs-Loffler  bacilli  are  moderate-sized  rods,  usually 
slightly  bent,  and  of  the  same  average  length  as  tubercle 
bacilli,  but  from  one  and  a  half  to  twice  as  thick,  but  they 
vary  materially  in  shape  and  size,  especially  in  length. 
The  simple  bacilli  are  usually  curved,  but  it  is  not  unusual 
to  find  wedge-shaped  bacilli  and  club-shaped  organisms. 
They  are  frequently  divided  into  segments.  They  are 
fixed,  and  possess  no  spores.  They  stain  readily  by  Gram's 
method  and  with  Loffler's  alkaline  methyl-blue,  their  ends 
staining  more  deeply  than  the  middle.  They  are  semi- 
aerobic,  and  thrive  best  at  the  temperature  of  the  body, 
viz.  98  to  100°  P.,  on  a  mixture  of  blood  serum  and  nutrient 
bouillon.  They  are  found  on  the  surface  of  the  false  mem- 
brane, or  in  its  substance,  but  they  are  always  separated 
from  the  true  mucous  membrane  by  a  layer  of  lymph  con- 
taining leucocytes.    Dr.  Dillon  Brown  says  that  the  most 

332 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  333 

ready  method  of  detecting  this  bacillus  is  to  detach  a 
small  piece  of  membrane  and  place  it  for  five  minutes  in 
a  2  per  cent,  solution  of  boric  acid.  The  piece  of  mem- 
brane is  then  drawn  along  the  surface  of  sterilized  blood 
serum  in  a  test-tube,  and  the  serum  is  afterwards  main- 
tained at  a  temperature  of  98°  F.  If  bacilli  are  present, 
characteristic  small  white  and  rounded  colonies  are  visible 
along  the  track  of  inoculation,  sixteen  hours  after  it  has 
been  made.  The  centre  of  the  colonies  are  more  opaque 
than  the  periphery,  and  they  grow  so  rapidly  that  they 
are  usually  well  formed  before  any  other  micro-organisms 
have  begun  to  form  colonies  at  all  visible  to  the  naked  eye. 
A  second  or  third  preparation,  however,  must  be  made 
before  a  pure  cultivation  is  obtained.  The  virulence  of 
the  cultivations  becomes  successively  diminished  if  they 
are  grown  on  agar-agar,  but  not  if  they  are  cultivated  on 
serum. 

To  overcome  the  difficulty  of  obtaining  sterilized  serum, 
Sakharof  suggests  the  use  of  hard-boiled  eggs,  from  one 
end  of  which  a  part  of  the  shell  has  been  removed  with 
ordinary  forceps,  so  that  the  shell-membrane  can  be  peeled 
off,  to  allow  of  the  necessary  inoculation  being  made.  To 
guard  against  contamination,  the  egg  can  be  turned  upside- 
down  in  a  common  egg-cup,  the  interior  of  which  has  been 
sterilized  by  allowing  the  flame  of  a  spirit-lamp  to  enter  it 
for  a  second  or  two. 

Dr.  Ball  advocates  growing  the  bacilli  upon  blood-clot 
which  has  been  sterilized  by  boiling  the  blood  in  a  test- 
tube  kept  in  a  water-bath  at  212°  F.  for  ten  minutes,  or 
until  it  has  become  quite  solid  and  of  a  chocolate  colour. 
He  claims  that  the  greyish- white  colonies  are  better  seen 
on  a  dark  background  than  when  they  are  grown  upon  a 
transparent  surface.  It  should  be  remembered,  however, 
that  the  growth  of  the  organisms  is  much  slower  when 


334      THE    SURGICAL    DISEASES    OF    CHILDREN 

they  are  cultivated  on  a  medium  which  has  been  heated  to 
a  temperature  of  212°  F. 

The  bacilli  in  pure  cultivations  possess  the  power  of 
producing  membranous  exudations  upon  the  various  mu- 
cous surfaces  of  the  body.  They  also  form  poisonous 
substances  or  toxines  capable  of  causing  constitutional 
symptoms  when  they  can  gain  access  to  the  blood-vessels 
or  lymphatic  channels,  and  through  them  to  the  tissues. 
These  toxic  products,  however,  only  appear  to  be  active 
when  they  are  introduced  under  conditions  predisposing 
to  diphtheria,  for  many  persons  and  animals  are  immune 
to  their  effects.  They  act  especially  upon  the  peripheral 
nerves,  causing  segmental  neuritis,  and  upon  the  muscles, 
leading  to  fatty  degeneration. 

The  pure  and  the  mixed  forms  of  the  disease  are  some- 
times clearly  defined  in  the  rare  joint  affections  seen  after 
an  attack  of  diphtheria.  The  neuralgia  of  the  joint,  the 
serous  arthritis  and  the  periarthritis  are  due  to  the  toxic 
products  of  the  pure  bacillus,  whilst  the  acute  and  chronic 
suppurations  are  the  results  of  the  bacillus  acting  in  con- 
junction with  septic  microbes.  The  differences  in  the 
mortality  of  the  various  outbreaks  are  no  doubt  to  be 
attributed  to  the  same  cause. 

A  knowledge  of  these  pathological  facts  has  recently  led 
to  great  alterations  in  the  recognition  and  in  the  treat- 
ment of  diphtheria.  It  has  shown  the  necessity  of  treat- 
ing diphtheria  as  a  local  disease,  and  as  one  whose  source 
is  in  reality  outside  the  body  ;  so  that  if  the  bacilli  can  be 
destroyed,  the  poisonous  bodies  resulting  from  their  life 
and  growth  can  be  effectively  dealt  with  by  the  tissues 
themselves.  It  should,  however,  be  borne  in  mind  that 
every  croupoiis  inflammation  of  a  mucous  membrane  is  by 
no  means  to  be  considered  as  true  diphtheria,  and  that  the 
only  certain  means  of  diagnosis  at  our  disposal  is  that  of 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  2,35 

inoculation  upon  guinea-pigs  and  pigeons,  and  of  bacterio- 
logical examination,  which  requires  an  elementary  know- 
ledge of  the  ordinary  methods  employed  in  bacteriology. 
The  bacteriological  examination,  however,  is  of  great  im- 
portance in  regard  to  prognosis ;  for  the  fewer  the  bacilli 
present,  and  apparently  the  smaller  they  are,  the  less 
severe  will  be  the  attack. 

Treatment.  By  Antitoxin. — A  certain  degree  of  im- 
munity from  diphtheria  can  be  conferred  upon  animals  for 
a  short  time  by  inoculating  them  with  attenuated  cultures 
of  the  Klebs-Loffler  bacillus,  or  by  injecting  a  suitable 
quantity  of  the  serum  of  an  animal  who  has  suffered  from 
the  disease  in  some  form  which  has  conferred  immunity 
upon  it.  The  means  by  which  this  immunity  is  obtained 
are  as  yet  unknown,  but  it  is  perhaps  due  to  the  formation 
of  antitoxins  produced  by  the  cellular  elements  of  the  con- 
nective tissues.  In  April,  1893,  this  method  of  treatment 
was  extended  by  Behring  and  Kossel  from  animals  to 
human  beings,  for  they  inoculated  the  serum  of  immune 
goats  into  thirty  diphtheria  patients,  of  whom  twenty- 
four  recovered.  The  method  has  rapidly  become  fashion- 
able. It  has  been  suggested  that  it  may  be  used  as  a 
preventive  measure  in  the  case  of  children  who  have  been 
exposed  to  the  risk  of  contagion,  in  which  case  only  a  small 
dose  is  required  ;  but  hitherto  it  has  been  chiefly  employed 
as  a  curative  method  for  those  actually  affected  with  the 
disease,  when  a  much  larger  dose  is  required.  The  results 
appear  to  have  been  satisfactory,  and  the  method  has  been 
highly  recommended,  though  we  still  require  further  evi- 
dence of  its  utility  in  extensive  epidemics.  Too  much, 
however,  must  not  be  expected  of  it,  for  it  does  not  pro- 
tect the  individual  for  any  length  of  time,  nor  does  it  in 
any  way  influence  the  action  of  the  septic  micro-organisms 
which  play  so  large  a  part  in  the  phenomena  of  ordinary 


336      THE    SURGICAL    DISEASES    OF    CHILDREN 

cases  of  diphtheria.  Inoculation  of  the  protective  serum, 
which  is  now  made  with  horse's  blood,  will  therefore  in  all 
probability  be  found  serviceable  only  in  the  earlier  cases 
of  unmixed  diphtheria. 

The  method  of  inoculation  is  simple.  The  injection  is 
usually  made  under  the  skin  of  the  abdomen,  which  should 
first  be  washed  with  a  1  in  20  solution  of  carbolic  acid. 
The  hypodermic  syringe  must  be  boiled  for  five  minutes 
immediately  before  the  inoculation,  to  render  it  sterile. 
The  dose  for  a  child  weighing  twenty  pounds  is  10  cubic 
centimetres,  which  is  equivalent  to  170  minims,  injected 
in  one  dose  under  the  skin.  In  a  severe  case  5  centi- 
metres may  be  again  inoculated  after  twelve  hours,  but  in 
any  case  it  is  advisable  to  inject  10  centimetres  twenty- 
four  hours  after  the  first  inoculation.  The  syringe  after  it 
has  been  used  is  to  be  boiled  for  one  minute.  The  inocula- 
tion may  lead  to  a  little  swelling  under  the  skin,  but  it 
usually  subsides  in  a  few  hours,  though  there  may  be  some 
tenderness  for  a  day  or  two. 

It  is  maintained  by  Heubner  and  Roux  that  the  anti- 
toxin can  be  introduced  with  absolute  impunity  even 
when  diphtheria  is  only  suspected,  the  sole  evil  effect 
being  an  erythematous  rash  which  appears  in  about  25 
per  cent,  of  the  cases  from  seven  to  nineteen  days  after 
the  injection  ;  but  Hansemann,  who  is  opposed  to  this 
method  of  treatment,  states  that  severe  renal  symptoms 
may  result  from  its  adoption,  whilst  Dr.  Washbourn  has 
observed  slight  arthralgia,  the  hips  being  most  frequently 
attacked. 

By  Fumigation.  —  Dr.  Northrup  has  recently  advo- 
cated the  method  of  calomel  fumigation  for  the  treatment 
of  acute  laryngeal  stenosis  occurring  in  children.  It  was 
originally  introduced  by  Dr.  J.  C.  Corbin,  of  Brooklyn,  in 
1881. 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  337 

A  tent-cot  is  made  in  the  ordinary  manner,  of  such  a 
size  that  it  contains  50  cubic  feet  of  air.  A  lighted  spirit- 
lamp  is  placed  in  a  wash-hand  basin  or  in  a  chamber-pot, 
and  a  strip  of  tin  is  bent  across  it.  Fifteen  grains  of 
chemically  pure  calomel  are  heaped  upon  the  strip  of  tin 
where  the  flame  of  the  spirit-lamp  touches  it.  The  sides 
of  the  cot  are  closed  for  a  quarter  of  an  hour,  and  the 
room  should  then  be  freely  ventilated.  Dr.  Northrup  re- 
commends that  the  fumigations  should  be  repeated  in 
severe  cases  at  intervals  of  two  hours  for  two  days  and 
two  nights,  the  intervals  being  prolonged  to  three  hours 
on  the  third  day,  four  hours  on  the  fourth  day,  and  subse- 
quently three  times  a  day.  There  is  more  or  less  anaemia 
after  prolonged  fumigation,  but  children  do  not  become 
salivated  though  they  have  diarrhoea,  and,  if  the  calomel 
is  mixed  with  corrosive  sublimate,  there  may  be  some 
conjunctivitis. 

In  the  simpler  forms  of  diphtheria  an  ice-collar  may  be 
applied  to  the  throat,  and  a  4  per  cent,  solution  of  chlorate 
of  potash  should  be  used  every  hour  as  a  gargle,  or  it  may 
be  sprayed  into  the  throat  and  nostrils  of  a  child  who  is  too 
young  to  gargle.  Hahn,  too,  recommends  that  in  the  early 
stages  of  diphtheria  half  a  pint  of  a  warm  2  per  cent,  solu- 
tion of  boric  acid  should  be  injected  into  the  rectum. 

Operative  Treatment.  Indications  for  surgical  in- 
terference.— The  surgeon  is  not  usually  called  upon  to 
make  a  diagnosis  of  diphtheria,  but  he  is  frequently  sum- 
moned to  relieve  the  symptoms  of  acute  laryngeal  dysp- 
noea. The  dyspnoea  comes  on  gradually  ;  at  first  there  is 
a  little  languor  with  feverishness,  and  a  peculiar  "  croupy  " 
cough.  The  movements  of  the  larynx  soon  become  exag- 
gerated, and  the  characteristic  furrow  of  inspiratory  re- 
cession becomes  marked.  It  is  best  seen  on  the  front  of 
the  chest  at  the  level  of  the  ensiform  cartilage.     At  each 


33§      THE    SURGICAL    DISEASES    OF    CHILDREN 

inspiration  the  supraclavicular  spaces  become  more  deeply 
hollowed.  The  breathing  in  uncomplicated  cases  is  rather 
laboured  than  hurried.  Attacks  of  suffocation  soon  de- 
velop ;  they  are  paroxysmal  at  first,  and  are  succeeded  by 
periods  of  comparative  ease  ;  but  as  the  disease  progresses, 
the  respites  become  briefer  and  are  less  pronounced,  the 
restlessness  increases,  the  face  and  the  extremities  become 
blue.  Finally,  as  the  lividity  increases,  the  restlessness 
diminishes,  the  features  assume  a  leaden  pallor,  the  child 
becomes  comatose  and  dies. 

No  child  should  be  allowed  to  die  in  such  a  manner,  for 
urgent  dyspnoea  is  the  great  sj^mptom  demanding  surgical 
interference  ;  and  when  it  is  present,  the  earlier  an  opera- 
tion is  performed  for  its  relief  the  better  it  will  be  for  the 
patient. 

Children  bear  dyspnoea  very  badly,  and  soon  succumb 
if  the  condition  be  not  removed  or  relieved. 

The  two  great  means  of  affording  relief  to  children 
suffering  from  dyspnoea  are  intubation  and  tracheotomy. 
Either  operation  may  be  performed  for  the  relief  of  in- 
creasing and  persistent  dyspnoea  due  to  mechanical  ob- 
struction in  the  larynx  and  upper  part  of  the  trachea. 

The  symptoms  by  which  the  urgency  of  the  dyspnoea  is 
measured  are  recession  of  the  soft  parts  of  the  chest  dur- 
ing inspiration,  stridulous  breathing,  and  lividity.  Mr.  R. 
W.  Parker's  axiom  should  be  remembered,  that  the  younger 
the  child  the  less  we  can  afford  to  delay  the  operation  to 
relieve  the  dyspnoea. 

Choice  of  Operation.— The  surgeon  has  therefore  to 
decide  very  promptly  whether  he  will  perform  intubation 
or  tracheotomy.  His  decision  must  be  final,  since  he  must 
not  intubate  with  the  idea  that  tracheotomy  may  be  per- 
formed afterwards  ;  for  when  this  has  been  done,  the  mor- 
tality has  been  found  to  be  prohibitive.      Intubation  is 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  339 

especially  adapted  for  those  cases  of  laryngeal  obstruction 
which  are  acute  in  onset  and  transient  in  duration,  as  in 
scalded  throat,  or  oedema  of  the  larynx,  if  the  case  is  seen 
early,  in  acute  laryngitis,  and  in  sudden  spasm  of  the 
glottis.  It  has  also  been  successfully  performed  for  cica- 
tricial stenosis  after  tracheotomy,  and  in  the  contraction 
following  the  various  forms  of  ulceration  of  the  larynx, 
whether  it  has  been  due  to  the  exanthemata  or  to  syphilis. 
Intubation  for  the  relief  of  dyspnoea  in  diphtheria  is  best 
suited  for  those  cases  in  which  there  is  great  dyspnoea  with 
comparatively  slight  constitutional  symptoms,  and  without 
the  formation  of  much  membrane.  Intubation  with  the 
ordinary  O'Dwyer's  tubes  is  not  adapted  for  cases  in  which 
the  trachea  is  filled  with  membrane,  nor  should  the  opera- 
tion be  performed  when  the  naso-pharynx  is  extensively 
involved.  It  is  especially  useful  in  children  under  two 
years  of  age,  and  it  has  the  additional  advantage  of  not 
requiring  an  anaesthetic  or  an  incision.  This  is  advan- 
tageous to  the  surgeon  in  several  ways,  for  it  often  allows 
the  operation  to  be  done  earlier  than  the  child's  relatives 
would  otherwise  permit,  haemorrhage  is  avoided,  there  is 
no  chance  of  the  condition  being  rendered  worse  by  wound 
infection,  and  the  air  is  naturally  warmed  and  filtered  be- 
fore it  enters  the  lungs,  so  that  there  is  a  diminished  risk 
of  pneumonia.  Intubation,  on  the  other  hand,  requires 
somewhat  greater  skill  on  the  part  of  the  operator  for  the 
neat  and  effective  introduction  of  the  tube.  He  should 
always  be  at  hand,  as  the  tube  is  sometimes  coughed  out, 
and  in  urgent  cases  there  is  danger  of  suffocation  if  it  be 
left  out  even  for  a  short  time,  although  it  often  happens 
that  after  removal  of  the  tube  there  is  complete  temporary 
relief  of  the  symptoms  of  dyspnoea,  apparently  due  to  the 
pressure  exerted  by  the  tube  leading  to  a  diminution  of 
the  oedematous  swelling.     This  temporary  improvement  is 


34Q 


THE    SURGICAL    DISEASES    OF    CHILDREN 


apt  to  prove  fallacious  unless  its  true  nature  be  recognised. 
Intubation  therefore  appears  to  be  better  suited  for  chil- 
dren in  a  public  institution  or  where  the  surgeon  can  be 
obtained  without  delay.  Mr.  Staveley,  my  late  house- 
surgeon,  showed  some  years  ago  that  very  considerable 
quantities  of  membrane  and  of  tenacious  secretion  could  be 
discharged  through  an  intubated  larynx ;  and  his  obser- 


Fig.    36.  —  Instiuments    employed   during    intubation   of   the   larynx  by 
O'Dwyer's  method. 

vations  have  been  fully  confirmed  by  all  who  have  had 
occasion  to  perform  the  operation  many  times. 

Intubation  of  the  Larynx. — The  operation  of  intu- 
bation of  the  larynx36  as  opposed  to  its  catheterisation  was 
originally  proposed  by  Bouchut  in  1857,  and  was  reintro- 
duced by  O'Dwyer  in  1885.  The  indications  for  the  opera- 
tion are  urgent  and  progressive  dyspnoea  due  to  causes 
chiefly  acting  above  the  vocal  cords. 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  34  I 

The  instruments  represented  in  fig.  36  are  required 
in  O'Dwyer's  operation,  of  which  alone  I  have  had  any 
experience.  They  are  a  gag,  two  or  three  tubes,  an 
introducer  (the  second  instrument  from  the  top),  on  to 
which  the  pilot  or  obturator  is  screwed,  the  pilot  varying 
in  size  for  each  tube,  and  some  stout  silk.  The  tracheo- 
tomy tubes  and  instruments  should  also  be  in  readiness. 
The  tube  is  a  stout  perforated  piece  of  metal  with  an 
expanded  end,  provided  with  a  small  hole,  through  which  a 
silk  ligature  can  be  passed  to  recover  the  tube  in  case  it 
should  fall  into  the  oesophagus  whilst  it  is  being  intro- 
duced. The  tubes  are  made  self-retaining  by  increasing 
their  narrow  transverse  diameter  at  the  centre,  so  as  to 
make  them  nearly  cylindrical  in  the  middle,  whilst  they 
taper  off  at  the  ends  to  form  a  double  wedge.  In  buying 
them,  care  should  be  taken  to  see  that  the  pilot  projects  a 
short  distance  beyond  the  lower  end  of  the  tube,  and  also 
that  the  lower  end  is  stout  and  very  blunt,  as  a  sharp  edge 
sometimes  causes  troublesome  symptoms.  An  indicator, 
represented  in  the  figure,  is  supplied  to  enable  the  surgeon 
to  ascertain  the  appropriate-sized  tube  to  use.  A  tube 
which  reaches  from  the  bottom  square  edge  of  the  indicator 
to  the  figure  1  is  suited  for  an  average  child  of  twelve 
months  old,  that  which  reaches  from  the  bottom  to  the 
figure  3  is  for  a  child  of  three  years  old,  and  so  on  up  to 
twelve.  It  should  be  borne  in  mind  that  the  tubes  are 
made  for  an  average  child,  and  they  are  usually  too  small 
for  the  individual,  so  that  it  is  better  to  take  a  size  larger 
than  the  index  points  out ;  for  if  too  small  a  tube  be  selected, 
there  is  a  danger  of  its  being  coughed  out  too  easily.  ' 

The  tube  is  threaded  with  a  silk  ligature,  measuring 
about  18  inches  in  length,  and  passed  through  the  hole 
in  its  expanded  end.  It  is  then  warmed  and  placed  upon 
the   pilot,  which   has  been  previously  screwed  on  to  the 


342      THE    SURGICAL    DISEASES    OF    CHILDREN 

introducer.  Two  assistants  are  necessary.  The  child, 
as  in  the  annexed  diagram  (fig.  37)  is  held  upright  in 
front  of  the  surgeon  by  one  assistant,  whose  duty  it  is 
to  hold  him  firmly  and  prevent  movements  of  his  body. 
The  best  plan  of  keeping  him  quiet  is  to  wrap  a  sheet 
or  rug  round  him  so  as  to  include  his  arms.     A  gag  is 


Fig.  37. — Semi-diagratnmatic  representation  of  the  method  of  introducing 
an  O'Dwyer's  tube  for  intubation  of  the  larynx. 

then  placed  in  the  left-hand  corner  of  his  mouth  and  is 
handed  to  the  second  assistant,  who  holds  it  firmly,  and  at 
the  same  time  steadies  the  head  in  such  a  position  that  it 
is  neither  fully  extended  nor  yet  flexed  upon  the  sternum. 
The  surgeon  then  takes  up  the  introducer  in  his  right  hand, 
and  winds  the  thread  attached  to  the  tube  round  his  little 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  343 

finger.  He  pushes  his  left  index  finger  down  the  throat 
until  he  is  able  to  raise  the  epiglottis  and  feel  the  rinia 
glottidis.  The  introducer,  with  the  tube  at  its  end,  is  held 
in  the  right  hand,  so  that  it  first  lies  parallel  with  the 
patient's  chest ;  the  handle  is  then  rapidly  elevated,  and 
the  tube,  guided  by  the  left  index  finger,  is  passed  lightly 
into  the  larynx.  As  soon  as  the  tube  is  well  in  position,  it 
is  pushed  off  the  pilot  by  pressing  a  lever  in  the  handle  of 
the  introducer,  which  is  then  withdrawn.  The  tube  must 
be  well  pushed  home  until  its  expanded  end  lies  upon 
the  top  of  the  glottis,  or  there  is  a  tendency  for  it  to  be 
expelled  by  coughing  ;  and  a  hold  must  be  retained  at  the 
same  time  upon  the  silk,  lest  during  the  manipulation 
the  tube  pass  into  the  oesophagus  instead  of  into  the 
glottis. 

The  operation  is  rapidly  and  accurately  performed  with 
comparatively  small  practice ;' and  for  the  purpose  of  ac- 
quiring a  sufficient  amount  of  dexterity,  Prof.  Heubner  has 
described  a  phantom  or  model  in  the  Jahrb.f.  kindcrhk.,  vol. 
xxxvi.,  p.  161.  The  introduction  of  the  tubes  should  never 
take  more  than  half  a  minute,  and  it  can  readily  be  accom- 
plished in  eight  to  ten  seconds.  No  force  must  be  employed. 
The  silk  thread  attached  to  the  expanded  part  of  the  tube 
may  be  secured  by  looping  it  round  the  ear  ;  or,  if  the  tube 
is  to  be  left  in  the  larynx  for  any  length  of  time,  it  may 
be  removed  after  an  interval  of  a  quarter  of  an  hour,  when 
the  first  fit  of  coughing  has  subsided,  and  as  soon  as  the 
surgeon  has  assured  himself  that  the  respiration  is  satis- 
factory. The  gag  must  then  be  re-introduced,  the  string 
cut,  and  the  surgeon  should  keep  his  finger  on  the  tube  .until 
the  string  is  pulled  out.  The  tube,  which  was  only  allowed 
to  remain  for  twelve  hours  at  most  when  the  operation  was 
first  suggested,  has  been  left  in  the  larynx  for  longer  and 
longer  periods,  until  at  the  present  time  three  or  four  clays 


344      THE    SURGICAL    DISEASES    OF    CHILDREN 

are  often  allowed  to  elapse  before  it  is  withdrawn,  unless 
any  symptoms  arise  to  render  its  earlier  removal  necessary. 

Treatment  after  Intubation.— If  the  tube  be  removed 
too  soon,  sudden  and  urgent  dyspnoea  sometimes  occurs, 
and  this  needs  a  speedy  re-introduction  of  the  tube.  The 
surgeon  should  not  be  in  too  great  a  hurry  to  leave  a 
child  after  he  has  extracted  the  tube,  even  though  for  the 
first  half -hour  it  seems  to  breathe  comfortably. 

A  child  who  has  been  intubated  should  be  kept  in  bed 
and  in  a  room  at  a  uniform  temperature  of  65°  P.  His 
feeding  constitutes  the  great  difficulty,  and  even  with 
every  care  children  take  much  less  food  after  intubation 
than  after  tracheotomy.  Soft-boiled  eggs,  oatmeal  porridge 
made  with  milk,  well-boiled  bread  and  milk,  and  beef 
essence  with  brandy,  usually  form  the  staple  diet.  Soft 
solids  are  taken  more  easily  than  fluids,  which  have  a 
tendency  to  pass  into  the  larynx.  The  annexed  figure 
(fig.  38),  copied  by  the  kind  permission  of  Dr.  Ball  from 
his  excellent  work  on  intubation,  shows  the  manner  in 
which  the  food  must  be  administered ;  the  child  being 
placed  either  upon  its  back  or  on  its  stomach,  and  with 
the  head  lower  than  the  body.  Warm  water  enemata  and 
small  pieces  of  ice  to  suck  will  allay  the  thirst  which  is  so 
constant  a  symptom  of  these  inflammatory  conditions. 

When  there  is  much  clogging  of  the  naso-pharynx  with 
membrane,  the  nostrils  must  be  repeatedly  and  gently 
cleansed  by  means  of  a  probe  armed  with  absorbent  cotton- 
wool soaked  in  a  1  or  2  per  cent,  solution  of  hydrogen 
peroxide,  alone  or  mixed  with  two  or  three  parts  of  lime- 
water  ;  or  a  1  in  40  solution  of  carbolic  acid.  Dr. 
Jacobi  recommends  that  these  solutions  should  be  gently 
injected  from  a  small  glass  syringe  through  a  conical 
nozzle  of  soft  rubber.  The  local  remedies  should  always 
be  applied  in  a  recumbent  or  semi-recumbent  posture,  and 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  345 

the  child  should  not  be  taken  out  of  bed  more  frequently 
than  is  necessary. 

Sequelae.  —  Intubation    in    a    few    cases    has     been 
followed    by  extensive  ulceration,    with    necrosis   of   the 


Pig.  38.— Method  of  feeding  a  child  after  intubation  of  the  larynx.    (Copied 
by  permission  from  Dr.  Ball's  work  on  Intubation.) 

cartilages  ;  but  this  is  fortunately  quite  exceptional.  The 
tube  has  fallen  into  the  trachea,  and  has  had  to  bo 
removed  by  tracheotomy,  and  it  has  been  swallowed,  but 
without  any  bad  result.  Careful  selection  of  a  tube  of  the 
proper  size  will  render  these  accidents  less  likely  to  occur. 


34-6      THE    SURGICAL    DISEASES    OF    CHILDREN 

Death  sometimes  occurs  during  the  act  of  intubation, 
or  the  dyspnoea  is  so  urgent  that  the  tube  has  to  be 
withdrawn  and  tracheotomy  performed  at  once.  In  all 
cases  the  physical  signs  in  the  chest  must  be  carefully 
examined  two  or  three  times  a  day  so  long  as  the  tube  is 
left  in  the  larynx. 

Removal  of  the  Tube.— The  removal  of  the  tube  is 
always  more  difficult  than  its  introduction,  and  it  may  be 
necessary  to  give  the  child  an  ansesthetic,  though  this 
shotild  not  be  done  if  it  can  be  avoided.  The  patient  is 
placed  in  the  same  position  as  for  the  introduction  of  the 
tube,  if  it  is  to  be  removed  without  giving  chloroform.  The 
gag  is  introduced,  and  the  surgeon  passes  his  left  fore- 
finger down  the  throat  until  he  feels  the  end  of  the  tube 
lying  in  the  glottis.  He  takes  the  extractor  in  his  right 
hand  (represented  in  fig.  36  as  the  uppermost  instrument). 
The  extractor  consists  of  a  pair  of  forceps  whose  ends  are 
serrated  upon  the  outside.  The  instrument  is  passed  along 
the  finger  until  the  points  are  felt  to  enter  the  upper  end 
of  the  tube ;  it  is  then  pushed  well  home,  the  blades  are 
opened,  and  the  tube  is  withdrawn.  The  handle  of  the 
extractor  must  be  carried  well  downwards  towards  the 
child's  chest,  or  considerable  difficulty  will  be  experienced 
in  getting  the  tube  past  the  soft  palate.  The  greatest 
gentleness  and  patience  are  required  in  extraction,  as  very 
serious  damage  may  be  done  to  the  larynx  and  the  sur- 
rounding parts  by  even  a  slight  amount  of  violence.  Mr. 
Staveley  has  attached  a  small  ring  to  the  side  of  the  in- 
troducer, so  that  the  thread  from  the  tube  may  be  passed 
through  it,  and  thus  give  more  complete  control  over  the 
tube  than  can  usually  be  obtained. 

Results.— The  mortality  in  cases  of  diphtheria  treated 
by  intubation  appears  to  be  nearly  identical  with  that 
after  tracheotomy.      Drs.  Prescott   and    Groldthwait   find 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  347 

that  in  2,815  cases  of  intubation  recovery  took  place  in 
32-2  per  cent.,  whilst  after  23,941  cases  of  tracheotomy 
there  were  28-67  cured.  The  tube  in  their  intubation  cases 
was  worn  for  an  average  period  of  five  days  and  eighteen 
hours,  and  they  say  that  age  has  a  decided  effect  upon  this 
time,  for  the  younger  the  child  the  longer  must  the  tube 
be  kept  in  the  larynx. 

Tracheotomy,37  History.  —  The  air-passages  were 
opened  by  Asclepiades  of  Bithynia  a  century  before  Christ, 
and  the  operation  was  performed  and  recommended  by 
Antyllus  at  the  end  of  the  third  or  beginning  of  the 
fourth  century.  It  was  reintroduced  in  the  sixteenth 
century  by  Benevieni  and  Fabricius  ab  Acquapendente ; 
but  the  modern  operation  only  dates  from  the  time  of 
Bretonneau  and  Trousseau,  who  in  1825  and  1833  re- 
spectively performed  it  for  the  relief  of  diphtheria. 

Indications.  —  Tracheotomy  is  performed  either  as  a 
prophylactic  measure  before  operations  upon  the  mouth 
and  larynx  in  which  much  bleeding  is  anticipated,  or  as  a 
means  of  providing  an  additional  supply  of  air  in  cases 
of  obstruction  due  either  to  mechanical  causes  or  to 
inflammatory  conditions,  as  well  as  for  the  removal  of 
foreign  bodies  from  the  trachea.  The  indications  for  its 
performance  are  the  same  as  for  intubation,  viz.  urgent 
and  progressive  dyspnoea ;  but  tracheotomy  is  usually  done 
at  a  later  period  than  intubation.  It  is  employed  for  the 
relief  of  obstruction  due  to  the  presence  of  a  foreign 
body,  or  from  that  caused  by  alterations  in  the  shape  and 
position  of  the  trachea  owing  to  goitre  or  other  tumours  of 
the  neck.  It  is  sometimes  necessary  to  relieve  by  this 
means  the  obstruction  caused  by  the  pressure  of  a  retro- 
pharyngeal or  other  cervical  abscess,  or  it  may  be  per- 
formed for  active  ulceration  of  the  larynx  due  to  syphilis 
or  tubercle,  as  well  as  for  new  growths  in  the  larynx. 


348      THE    SURGICAL    DISEASES    OF    CHILDREN 

It  is  of  the  utmost  importance  that  tracheotomy  should 
be  performed  before  the  child  is  moribund.  One  of  the 
great  advances  in  recent  surgery  has  been  a  recognition 
of  the  fact  that  early  tracheotomy  means  speedy  recovery 
in  suitable  cases  of  dyspnoea,  though  this  maxim  applies 
less  to  the  treatment  of  diphtheria  than  to  mechanical 
obstruction  to  the  entrance  of  air  into  the  lungs.  The 
operation  should  be  performed  at  once  in  all  cases  of 
diphtheria  where  intubation  has  not  been  tried  owing  to 
the  abundant  formation  of  membrane,  the  severity  of  the 
tracheal  inflammation,  and  when  the  naso-pharynx  is 
involved.  Pneumonia  does  not  seem  to  be  a  bar  to  the 
performance  of  tracheotomy  in  diphtheria,  though  a 
typhoidal  condition  owing  to  septic  absorption  appears  to 
contra-indicate  the  operation,  or  at  any  rate  to  militate 
greatly  against  its  success. 

The  Operation.  —  The  instruments  required  for  the 
operation  in  a  child  are  Durham's  canulas  with  mov- 
able collars,  Parker's  angular  tracheotomy  tubes,  Nos. 
18,  22,  and  28  being  the  most  useful  sizes  ;  or  if  it  is  a 
preliminary  to  an  operation  upon  the  larynx,  a  Trendelen- 
burg's tube,  which  is  provided  with  an  india-rubber  ring 
capable  of  being  blown  up  so  as  to  occlude  the  lumen  of 
the  trachea,  as  is  seen  in  fig.  39 ;  a  two-bladed  tracheal 
dilator ;  two  or  three  pairs  of  pressure  forceps ;  a  couple  of 
aneurism  needles  or  blunt  hooks  to  serve  as  retractors  ; 
a  sharp  hook ;  two  moderate-sized  scalpels,  which  must 
be  very  sharp ;  tapes,  and  a  few  turkey's  or  pheasant's 
feathers  to  clean  out  the  trachea  before  the  tube  is  intro- 
duced. 

It  is  better  to  give  chloroform,  unless  the  child  be 
already  narcotised  by  the  circulation  of  impure  blood  ;  but 
only  enough  should  be  administered  to  enable  the  child  to 
breathe  quietly  ;  and  it  is  not  necessary  to  continue  it  after 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  349 

the  skin  incision  has  been  made,  unless  the  child  begins  to 
struggle  or  unless  the  introduction  of  the  canula  produces 
continued  and  convulsive  coughing.  No  regard  is  paid  in 
England  to  the  position  of  the  opening  so  long  as  it  is  in 
the  middle  line,  but  in  Germany  there  is  an  increasing 
school  of  surgeons  who  advocate  the  opening  of  the  trachea 
below  the  isthmus  of  the  thyroid,  and  who  in  any  case 
carefully  avoid  injuring  the  cricoid  cartilage,  as  they 
believe  that  its  division  renders  it  difficult  to  keep  the  tube 
in  a  satisfactory  position  ;  a  displacement  of  the  tube  due 


Fig.  39.— Trendelenburg's  tampon  tracheotomy  tube  for  blocking  the  trachea 
during  operations  upon  the  larynx. 

to  this  cause,  however,  is  more  likely  to  occur  in  adults 
than  in  children.  As  soon  as  the  child  is  unconscious,  the 
neck  is  made  as  prominent  as  possible  by  removing  the 
pillows  from  the  head,  and  placing  a  narrow  cushion  under 
the  shoulders,  and  a  rolling  pin  or  a  wine  bottle  wrapped 
in  a  cloth  answers  this  purpose  very  well. 

The  skin  incision  is  made  exactly  in  the  middle  line  of 
the  neck,  its  centre  being  opposite  the  point  where  the 
surgeon  intends  to  open  the  trachea.     It  should  only  be 


350      THE    SURGICAL    DISEASES    OF    CHILDREN 

skin-deep,  and  shcmld  be  too  long  rather  than  too  short,  so 
as  to  prevent  that  escape  of  air  into  the  tissues  which  some- 
times happens  if  the  opening  in  the  skin  and  trachea  do 
not  correspond.  When  the  condition  of  the  child  allows 
of  a  leisurely  operation,  the  different  tissues  should  be 
carefully  and  cleanly  divided,  until  the  trachea  is  reached ; 
scratching  and  tearing  the  tissues  being  especially  avoided 
in  cases  of  mixed  infection,  as  it  may  lead  to  troublesome 
and  extensive  suppuration.  The  greatest  care  must  be 
taken  to  keep  strictly  in  the  middle  line,  and  for  this 
reason  retractors  should  be  used  as  little  as  possible.  They 
should  be  given  into  the  charge  of  a  single  assistant,  who 
retracts  each  side.  Some  little  care,  too,  should  be  taken 
not  to  make  too  extensive  a  division  into  the  deep  cervical 
fascia,  nor  to  raise  it  too  freely  from  the  trachea ;  for  Dr. 
Champneys  has  shown  that  air  may  pass  behind  it,  and 
so  penetrate  into  the  mediastinum,  causing  mediastinal 
emphysema,  and  that  the  air  may  even  burst  through 
the  mediastinum  and  distend  the  pleural  sac  leading  to 
pneumothorax.  It  should  be  divided  by  a  small  trans- 
verse incision. 

The  isthmus  of  the  thyroid  can  usually  be  pulled 
upwards  or  downwards,  as  the  case  may  be,  or  it  may  be 
divided. 

As  soon  as  the  trachea  is  exposed,  the  sharp  hook  may  be 
passed  beneath  the  cricoid  cartilage  to  steady  it  for  an 
instant  whilst  its  second  and  third  rings  are  divided  up- 
wards and  exactly  in  the  middle  line,  or  the  larynx  may 
often  be  sufficiently  steadied  by  holding  it  lightly  between 
the  finger  and  thumb.  In  opening  the  trachea,  the  point 
of  the  knife  must  not  be  allowed  to  injure  its  posterior 
wall,  and  a  sufficiently  large  aperture  must  be  made 
into  it  to  allow  of  the  free  escape  of  air,  mucus,  and 
inflammatory   products.     The   dilator   is   introduced   into 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  35  I 

the  trachea  along  the  side  of  the  knife,  its  blades  are 
separated,  and  the  first  ring  of  the  trachea  may  be  divided 
as  the  knife  is  withdrawn.  The  opening  in  the  trachea  is 
now  dilated,  and  if  the  operation  has  been  performed  for 
the  relief  of  diphtheria,  as  much  membrane  is  allowed  to 
escape  as  possible  ;  a  feather  is  then  introduced  and  twisted 
round  and  round  to  clear  the  lumen  of  the  trachea  still 
further  before  the  tube  is  put  into  place.  An  interval 
should  always  be  allowed  to  elapse  between  the  opening 
of  the  trachea  and  the  introduction  of  the  tube.  The 
dyspnoea  is  sometimes  so  great  that  the  leisurely  opera- 
tion here  described  cannot  be  performed,  for  the  child  may 
cease  to  breathe  before  the  trachea  can  be  opened.  The 
dilator  must  be  introduced  in  these  cases  as  speedily  as 
possible,  and  then  artificial  respiration  must  be  diligently 
carried  out  by  Howard's  method. 

The  operator  stands  on  the  right  side  of  the  patient 
to  pass  the  tube.  He  takes  the  dilator  in  his  left  hand, 
and  the  tracheotomy  tube  in  his  right,  the  upper  part  of 
the  tube  pointing  to  the  right  of  the  patient.  He  then 
introduces  the  lower  end  of  the  tube  into  the  trachea,  and 
by  a  slight  tour-de-maitre  brings  it  into  its  proper  position. 
It  should  be  remembered,  in  selecting  a  tube,  that  the 
shorter  and  wider  it  is  the  more  comfortable  it  will  be  to 
wear.  It  should  be  provided  with  a  movable  collar,  and 
it  is  kept  in  position  by  tapes  tied  at  the  back  of  the  neck. 

After-Treatment. — The  success  of  the  operation  de- 
pends greatly  upon  the  after-treatment,  consisting  essenti- 
ally in  proper  feeding  and  in  causing  the  child  to  breathe 
warm  air  saturated  with  moisture.  Pain  and  the  obstruc- 
tion caused  by  the  tube  often  render  deglutition  painful 
and  difficult.  A  good  nurse,  however,  can  generally  coax 
the  child  to  take  enough  nourishment  to  prevent  the 
necessity  of  having  recourse  to  artificial  feeding.     Milk, 


352      THE    SURGICAL    DISEASES    OF    CHILDREN 

either  plain  or  peptonised,  and  with  an  egg  beaten  np 
in  it,  raw  meat-juice  or  chicken-broth,  with  stimulants, 
are  generally  sufficient.  Four  to  six  ounces  of  food  should 
be  given  every  four  hours,  according  to  the  age  of  the 
patient,  and  as  much  as  three  ounces  of  brandy  may  be 
given  in  the  course  of  twenty-four  hours.  The  quantity 
of  food  may  be  gradually  increased,  for  the  larger  the 
quantity  taken  the  less  often  will  it  be  requisite  to  rouse 
the  patient  to  give  it.  Twenty  to  forty  ounces  of  milk  a 
day  is  an  average  amount  of  food  for  an  invalid  child  of 
four  years  old,  and  an  endeavour  should  be  made  to  get 
this  amount  assimilated,  for  those  who  take  their  food 
badly  after  tracheotomy  are  more  likely  to  die  than  those 
who  take  it  well.  Dr.  Habershon  points  out  that  vomit- 
ing, regurgitation,  or  dyspepsia  after  feeding,  indicate  that 
too  much  food  has  been  given. 

Feeding  by  the  nose  need  not  be  adopted  as  a  routine 
proceeding,  but  when  it  is  necessary  I  have  always  followed 
the  plan  recommended  by  my  friends  Drs.  Bullar  and 
Habershon,  of  introducing  a  No.  4  or  No.  6  soft  rubber 
catheter.  A  small  piece  of  glass  tubing  is  fixed  in  the 
outer  end  of  the  tube,  and  the  warm  fluid  food  is  placed  in 
a  glass  syringe  holding  four  to  six  ounces.  The  end  of  the 
brass  syringe  is  connected  with  the  glass  tube  by  a  piece 
of  drainage-tube.  There  is  usually  no  difficulty  in  passing 
the  soft  catheter  into  the  oesophagus,  and  after  the  first 
feeding  the  child  rarely  resents  its  repetition.  The  manipu- 
lation is  so  easy  that  the  patient  may  sometimes  be  fed 
without  being  awakened.  Perchloride  of  iron  and  the 
tincture  of  mix  vomica  should  also  be  administered  in  full 
doses. 

The  air  which  the  child  breathes  may  be  warmed  and 
saturated  in  several  ways ;  many  surgeons  employ  the 
"  steam  tent,"  arranged  by  fixing  a  lath  to  each  corner  of 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  2,53 

the  cot,  connecting  the  uprights  by  crossbars,  and  covering 
the  whole  framework  with  a  sheet.  A  thermometer  should 
be  hung  inside  the  tent,  on  a  level  with  the  head  of  the 
patient,  and  the  air  may  be  kept  saturated  by  means  of  a 
bronchitis  kettle.  The  temperature  of  the  room  should 
be  maintained  as  nearly  as  possible  at  70°  F.  Many 
surgeons  dispense  with  the  steam  tent,  and  content  them- 
selves with  a  thin  and  flat  sponge,  which  should  be  of 
coarse  texture.  It  is  wrung  out  of  a  warm  solution  of 
boric  acid,  and  is  placed  over  the  orifice  of  the  tube.  It 
must  be  frequently  renewed  during  the  first  twenty-four 
hours  after  the  operation,  and  it  may  then  be  replaced  by  a 
layer  of  moistened  gauze. 

When  the  operation  has  been  done  for  diphtheria,  the 
tongue  should  be  depressed  with  a  spatula,  and  the  pharynx 
should  be  repeatedly  sprayed  with  a  hand  spray  every 
three  hours  so  long  as  there  is  membrane,  and  afterwards 
every  six  hours.  The  same  operation  may  be  repeated  at 
the  trachea  rather  more  frequently,  the  spray  being  de- 
livered a  short  distance  from  the  mouth  of  the  tube.  Dr. 
Collier  and  Mr.  Pitts  recommend  a  spray  of  one  per  thou- 
sand corrosive  sublimate  (except  for  the  trachea)  in 
preference  to  the  ordinary  one  of  boric  acid,  which  some- 
times causes  irritation  of  the  mucous  membrane.  A  one  or 
two  per  cent,  of  peroxide  of  hydrogen  is  often  useful,  or  a 
solution  made  by  mixing  ten  grains  of  bicarbonate  of  soda 
with  an  equal  quantity  of  biborate  of  soda  in  an  ounce  of 
water  containing  two  drachms  of  glycerine.  A  drachm  of 
the  spray  should  be  used  on  each  occasion,  the  operation 
should  take  three  or  four  minutes,  and  an  interval  of  five 
seconds  should  bo  allowed  at  the  end  of  every  half-minute. 
Dr.  Collier  also  recommends  that  the  nose  should  be  douched 
with  a  warm  boric  acid  solution,  though  either  of  the 
"tiiers  may  be  employed,  every  three  hours,  and   that   it 

A    A 


354      THE    SURGICAL    DISEASES    OF    CHILDREN 

should  be  sprayed  with  the  corrosive  sublimate  after  each 
douching. 

Constant  and  assiduous  attention  must  be  paid  to  the 
tube.  It  must  be  cleaned  from  time  to  time  by  passing 
a  feather  along  it  with  a  rotatory  movement ;  but  the 
nurse  must  be  taught  how  to  catch  the  membrane  and  the 
mucus  as  it  is  coughed  up,  so  that  she  may  not  be  con- 
stantly feathering.  When  a  double  tube  has  been  used, 
as  is  now  the  rule,  the  inner  portion  must  be  withdrawn 
and  thoroughly  cleansed  every  two  hours,  so  long  as  any 
membrane  is  being  ejected  ;  but  the  outer  part,  under  ordin- 
ary conditions,  only  requires  taking  out  upon  alternate 
days,  though  if  there  is  very  much  membrane  it  should  be 
changed  daily. 

The  only  dressing  required  for  the  wound  is  a  little 
simple  ointment  on  a  piece  of  lint,  for  healing  generally 
takes  place  rapidly,  and  with  very  little  scarring.  The 
wound  sometimes,  however,  becomes  infected  with  diphthe- 
ritic or  suppurative  inflammation,  or  the  whole  neck  may 
become  swollen  from  acute  inflammation  of  the  connective 
tissue  and  lymphatic  glands.  These  conditions  add  greatly 
to  the  gravity  of  the  prognosis,  but  they  are  not  necessarily 
of  fatal  import.  The  suppurating  wound  is  treated  with 
dressings  of  peroxide  of  hydrogen  combined  with  insuffla- 
tions of  iodoform.  Iced  compresses  may  first  be  tried  in 
the  diffuse  inflammation ;  but  it  is  generally  necessary  to 
make  free  incisions  into  the  swollen  tissue,  carrying  the 
knife  through  the  deep  cervical  fascia,  and  taking  care  to 
perform  the  operation  with  the  least  possible  loss  of  blood. 

Dangers  of  the  Operation. — Tracheotomy  is  not  free 
from  danger  either  to  the  surgeon  or  to  the  patient.  Too 
many  deaths  are  annually  recorded  from  diphtheria  con- 
tracted during  the  performance  of  the  operation,  especially 
amongst  the  younger  members  of  the  profession,  already 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES   355 

reduced  in  strength  by  the  labours  and  anxieties  of  their 
first  responsible  public  appointments.  No  operator,  there- 
fore, ought  to  render  himself  liable  to  direct  inoculation  by 
sucking  the  wound  ;  and  if  there  is  reason  to  think  that  he 
has  become  accidentally  infected,  he  should  at  once  take 
antiseptic  precautions  by  washing  out  his  mouth  and 
gargling  with  a  1  in  40  solution  of  carbolic  acid.  If  the 
patient  does  not  die  on  the  table,  the  operation  having  been 
too  long  postponed,  he  may  succumb  within  five  days  of 
the  operation,  either  to  broncho-pneumonia  or  to  the  effects 
of  the  disease  for  which  the  operation  was  performed. 
Haemorrhage  at  the  time  of  operation  is  sometimes  trouble- 
some, and  it  must  be  treated  by  seizing  the  bleeding  points 
with  pressure  forceps.  If  blood  gains  access  to  the  trachea, 
the  two  cut  edges  of  the  tube  may  be  drawn  upwards  into 
the  wound,  and  the  trachea  may  be  freed  from  blood  in  the 
ordinary  manner. 

Fatal  haemorrhage  has  taken  place  in  a  few  very  unusual 
cases  some  time  after  the  performance  of  a  tracheotomy, 
owing  to  a  diphtheritic  inflammation  extending  to  the 
innominate  or  internal  jugular  veins,  or  from  ulceration  of 
the  innominate  or  common  carotid  arteries,  caused  by  the 
pressure  of  the  lower  end  of  the  tube.  Such  accidents  need 
hardly  enter  into  the  surgeon's  calculations,  but  he  should 
rather  be  on  his  guard  to  prevent  the  sudden  death  which 
more  often  takes  place  from  syncope  after  tracheotomy  has 
been  performed  for  the  relief  of  diphtheria. 

Removal  of  Tube. — The  tracheotomy  tube  should  be 
removed  as  soon  as  possible.  The  surgeon  may  withdraw 
it  four  or  five  days  after  the  operation  if  all  goes  well,  and 
watch  the  child's  breathing,  with  the  tracheal  dilator  handy 
in  case  of  accidents.  The  patient  sometimes  breathes  well 
from  the  first,  hut  it  much  more  frequently  happens  that 
he   has   to  be  educated  to  laryngeal  respiration,  for  the 


35^      THE    SURGICAL    DISEASES    OF    CHILDREN 

muscles  of  the  glottis  no  longer  work  harmoniously  with 
the  diaphragm  and  the  intercostals.  The  child  must  be 
taught  to  breathe  systematically,  first  by  closing  the  orifice 
of  the  tube,  and  then  by  doing  without  it  for  a  longer  or 
shorter  time.  The  difficulty  is  often  rather  mental,  from 
fright :  than  physical,  or  due  to  a  want  of  co-ordinating 
power.  The  process  of  education  in  these  cases  is  best 
carried  out  by  the  person  in  whom  the  child  has  most  confi- 
dence.    It  takes  on  an  average  about  a  fortnight. 

Tracheal   Stenosis. 

It  happens  in  a  certain  proportion  of  a  large  series  of 
tracheotomies  that  it  is  impossible  for  the  patient  to 
breathe  without  his  tube.  The  dyspnoea  comes  on  either 
directly  the  tube  is  removed,  or  after  a  shorter  or  longer 
interval.  Its  onset  is  sometimes  very  insidious,  and  the 
difficulty  in  breathing  may  be  more  marked  when  the 
patient  is  asleep.  Many  causes  lead  to  this  condition  ; 
the  obstruction  may  be  due  to  a  narrowing  of  the  glottis, 
owing  to  cicatrisation  of  the  cords,  or  to  anchylosis  of 
the  arytenoids,  followed  by  atrophy  of  the  posticus 
muscles,  and  this  is  most  likely  to  occur  when  the  tracheo- 
tomy has  been  performed  for  the  relief  of  conditions 
causing  injury  to  the  glottis,  such  as  scalds  or  the  swal- 
lowing of  foreign  bodies.  It  is  sometimes  due  to  papil- 
lomatous growths  within  the  larynx,  or  more  frequently 
to  masses  of  granulation  tissue,  which  may  become  con- 
verted into  fibrous  tissue,  forming  bands  of  adhesion  either 
just  above  or  just  below  the  orifice  in  the  trachea.  It  is 
said  (p.  349)  that  these  cases  are  most  likely  to  happen  when 
the  cricoid  cartilage  has  been  divided  in  the  high  opera- 
tion. Especial  care,  therefore,  should  be  taken  to  prevent 
this  unnecessary  injury,  though  from  the  small  size  of 
the  parts  in  a  young  child  such  division  is  by  no  means 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  357 

infrequent.  The  granulations  are  in  many  cases  un- 
doubtedly due  to  the  irritation  of  a  badly  fitting  tube, 
which  sets  up  ulceration  of  the  mucous  membrane,  and 
may  actually  cause  the  production  of  valve-like  prolonga- 
tions of  the  mucous  membrane.  The  obstruction  in  other 
cases  follows  extensive  necrosis  of  the  cartilaginous  rings 
of  the  trachea,  loss  of  elasticity  in  the  rings,  or  even  their 
displace  nent  at  the  point  of  division. 

Treatment.— When  the  inability  to  breathe  without  a 
tube  is  due  to  mechanical  causes,  and  respiration  is  impos- 
sible even  under  an  anaesthetic,  immediate  measures  must 
be  taken  to  ascertain  the  cause,  and,  if  possible,  to  remedy 
the  defect,  as  it  is  useless  to  wait  in  the  hope  that  time 
will  improve  matters.  Trelat  has  called  attention  to  the 
fact  that  in  stenosis  of  the  larynx  the  phonation  is  first 
affected,  whilst  in  stenosis  of  the  trachea  the  dyspnoea  is 
the  earlier  symptom.  The  existence  of  id?.eration  in  the 
trachea  is  recognised  by  the  blood-stained  sputum,  the 
cough,  and  the  foetid  breath.  In  such  cases  the  tube  should 
be  changed  for  one  which  fits  the  trachea  better  before  the 
irritation  has  led  to  the  formation  of  granulation  tissue. 
The  asymmetry  and  deformity  of  the  trachea  will  give  a 
clue  to  the  cause  of  the  obstruction  when  it  is  due  to 
defects  in  the  cartilaginous  framework.  There  is  no  satis- 
factory treatment  for  these  cases,  though  endeavours  may 
be  made  to  ameliorate  the  condition  by  the  use  of  the  triple 
dilating  tube.  The  treatment  of  laryngeal  obstruction  is 
a  little  more  favourable.  Macewen's  tracheal  catheter  may 
be  employed  in  cases  of  slight  obstruction,  the  instrument 
being  introduce  1  on  a  long  probe  through  the  mouth  into 
the  glottis,  or  upwards  through  the  tracheal  opening.  It 
must  be  so  arranged  in  either  case  that  it  extends  below 
the  wound  in  the  trachea,  and  it  must  be  kept  in  place 
until  the  tracheal  opening  is  completely  healed. 


358      THE    SURGICAL    DISEASES    OF    CHILDREN 

Operative  interference  is  much  more  frequently  needed 
in   these   cases.    The   wonnd   in   the   trachea    should   be 
thoroughly  explored  by  enlarging  the  incision ;  all  granu- 
lation tissue  and  bands  of  fibrous  tissue  must  be  freely 
dissected  away,  and  an  O'Dwyer's  tube  should  be  left  in 
the  glottis  until  the  external  wound  is  closed.     The  tube 
used  in  these  cases  is  larger  and  longer  than  that  used  for 
intubation,  and  it  may  be  left  in  the  larynx  for  a  fortnight 
at  a  time  ;  though  if  there  is  any  tendency  to  the  formation 
of  granulations  at  the  sides  of  the  epiglottis,  Dr.  O'Dwyer 
recommends  that  the  tube  should  be  removed  every  week, 
occasionally  changing  the  shape  or  size  of   the   head  or 
shoulder  of  the  tube.     Mr.  Bernard  Pitts  and  Mr.  Brook, 
who  have  had  much  experience  in  the  treatment  of  these 
very  troublesome  cases,  recommend  that  when  the  tube  is 
thus  left  in  position  for  long  periods  of  time,  it  should  not 
have  any  string  attached  to  it,  as  less  coughing  is  then 
caused.     The  tracheotomy  wound  should  be  kept  open  by 
using  the  hard  rubber  plug  devised  by  Messrs.  Pitts  and 
Brook,  so  long  as  the  intubation  is  maintained. 

All  measures  prove  ineffectual  in  many  of  these  cases, 
and  I  know  two  or  three  children  who  still  prove  them- 
selves reproaches  to  surgery  by  constantly  wearing  a 
tracheotomy  tube  in  spite  of  all  that  can  be  done  for  them. 
So  long  as  the  tube  is  being  worn,  the  surgeon  should 
assure  himself  that  the  wound  in  the  neck  is  not  being 
fretted  by  the  tube,  that  no  ulceration  is  occurring  either 
at  the  front  or  back  wall  of  the  trachea,  owing  to  any 
fault  in  the  length  or  curvature  of  the  tube,  and  that 
unduly  strong  solutions  are  not  being  sprayed  into  the 
trachea. 

Inflammatory  Conditions  of  the  Larynx. 
Syphilitic  and  tuberculous  inflammation  of  the  larynx 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  359 

occur  occasionally,  whilst  extensive  necrosis  of  the  laryn- 
geal cartilages  is  sometimes  met  with  after  typhoid  fever. 
There  are  a  few  recorded  cases  in  which  an  enlarged 
bronchial  gland  has  gained  admission  to  the  trachea  by  a 
process  of  ulceration,  and  has  caused  sudden  death  by 
asphyxia. 

SCALDS   OF   THE   PHARYNX  AND  LARYNX. 

Cause. — A  scalded  mouth  and  throat  is  quite  a  usnal 
farm  of  accident  in  children.  It  is  caused  either  by  their 
drinking  out  of  the  spout  of  a  teapot  or  kettle  containing 
very  hot  fluids,  or,  more  rarely,  by  the  actual  inhalation  of 
steam. 

Morbid  Anatomy.— The  scalded  mucous  membrane 
soon  becomes  oedematous,  and  its  surface  may  be  covered 
by  plastic  deposits  bearing  a  close  resemblance  to  the 
patches  of  diphtheria.  The  oedema  does  not  extend  below 
the  vocal  cords,  as  there  is  an  interruption  to  the  sub- 
mucous tissue  at  that  point. 

Symptoms. — The  symptoms  of  a  scalded  throat  vary 
with  the  amount  of  the  oedema  to  which  they  are  directly 
due.  Dyspnoea  is  therefore  the  most  prominent.  A  certain 
amount  of  shock  attends  all  the  more  severe  cases. 

Diagnosis. — The  inflammatory  conditions  have  to  be 
distinguished  from  the  other  causes  of  acute  laryngeal 
inflammation,  such  as  acute  cellulitis,  diphtheria,  and 
retropharyngeal  abscess.  The  scalding  at  the  angles  of 
the  mouth  and  the  peculiar  oedematous  condition  of  the 
injured  tissues  will  serve  to  distinguish  a  scald  from 
everything  else. 

Prognosis. — Scalds  are  always  dangerous  in  young 
children,  and  a  guarded  prognosis  mnsr  In-  given.  Re- 
covery usually  takes  place  in  the  slighter  forms. 


3 


6o      THE    SURGICAL    DISEASES    OF    CHILDREN 


Treatment. — The  treatment  is  essentially  symptomatic, 
and  is  directed  towards  the  relief  of  the  conditions  leading 
to  dyspnoea.  The  child  should  be  put  to  bed,  and  allowed 
to  breathe  moist  air ;  the  shock  should  be  treated  in  the 
ordinary  manner  by  warmth  and  the  administration  of  two 
or  three  grain  doses  of  ammonium  carbonate.  An  ice-collar 
may  be  placed  round  the  neck,  and  the  dyspnoea  should  be 
carefully  watched.  The  surgeon  should  intubate  the  larynx 
early,  if  the  difficulty  in  breathing  appears  to  be  increasing. 
Tracheotomy  nmst  be  performed  if  for  any  reason  intuba- 
tion is  impossible,  and  it  is  well  to  do  the  operation  before 
the  dyspnoea  has  become  so  urgent  as  to  weaken  the  child. 

Sequelae. — The  sequelse  are  not  usually  well  marked 
in  children,  but  some  amount  of  fibrous  stricture  may  be 
produced. 

NEW  GROWTHS. 

Chronic  laryngeal  obstruction  in  children  is  caused  by 
new  growths,  usually  papillomatous  and  multiple,  more 
rarely  cystic.  They  may  be  situated  upon  the  vocal  cords 
or  upon  the  ary-epiglottic  folds,  and  in  some  cases  they 
are  so  numerous  as  to  fill  up  the  whole  glottis.  They  are 
pale  pink  in  colour,  pedunculated,  and  are  set  so  closely 
together  as  to  form  an  uneven  and  cauliflower-like  mass. 

Symptoms. — They  are  either  congenital,  when  the 
child  cries  huskily  from  its  birth,  or  they  develop  later 
and  cause  more  or  less  urgent  dyspnoea  with  aphonia. 

Diagnosis. — The  diagnosis  in  older  children  is  easily 
made  by  laryngoscopic  examination,  but  in  infants  it 
must  be  mainly  symptomatic.  The  dyspnoea  due  to  the 
presence  of  papillomata  must  not  be  mistaken  for  that 
caused  by  laryngismus  stridulus,  for  it  is  more  constant 
and  it  is  not  relieved  by  improving  the  general  health  of 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  36 1 

the  child  or  by  removing  those  causes  of  reflex  irritation 
to  which  spasmodic  croup  is  usually  attributed. 

Treatment. — Single  growths  may  be  removed  by  the 
laryngeal  forceps  in  infants  and  in  older  children,  but 
nothing  short  of  tlryrotomy  is  of  use  when  the  growths  are 
multiple  and  threaten  to  block  up  the  glottis.  A  preliminary 
tracheotomy  must  be  performed  in  these  cases,  and  at  the 
time  of  the  major  operation  a  small  tampon  canula,  upon  the 
principle  (p.  348)  introduced  by  Trendelenburg  (fig.  39), 
should  be  used  to  prevent  the  access  of  blood  to  the 
bronchi.  Mr.  Bernard  Pitts,  in  some  recent  lectures  upon 
the  "  Surgery  of  the  Air  Passages  in  Children,"  however, 
says  that  if  proper  care  be  taken  to  arrest  the  bleeding  in 
the  ordinary  manner,  the  use  of  such  a  tube  is  unnecessary. 
He  employs  the  ordinary  tracheotomy  tube,  keeping  the 
trachea  above  it  packed  with  small  pieces  of  sponge,  each 
on  a  string.  -  The  child  is  put  into  the  ordinary  position 
for  tracheotomy,  the  thyroid  cartilage  is  exposed,  and  the 
alee  are  transfixed  laterally  by  means  of  a  needle  threaded 
with  aseptic  silk.  The  cartilage  is  then  divided  in  the 
middle  line  nearly  up  to  the  thyroid  notch.  The  two 
alee  are  separated,  the  silk  thread  is  drawn  out  and 
divided,  so  that  two  retractors  are  provided.  The  glottis 
is  thoroughly  exposed,  and  the  growths  are  then  snipped 
away  with  a  pair  of  scissors,  cocain  being  applied  from 
time  to  time  to  prevent  spasmodic  contractions  during 
this  manipulation.  Mr.  Pitts  thinks  that  a  fine  Paquelin 
cautery  passed  over  the  points  of  section  acts  more  satis- 
factorily than  the  chromic  acid,  which  is  usually  used  as 
a  caustic  in  these  cases.  The  silk  threads  are  withdrawn, 
and  the  two  alae  of  the  thyroid  cartilage  are  sutured,  the 
needle-holes  in  the  two  thyroid  cartilages  serving  as 
valuable  guides  in  obtaining  exact  approximation.  The 
skin  over  it  is  brought  together,  and  the  tracheotomy  tube 


J 


62      THE    SURGICAL    DISEASES    OF    CHILDREN 


is  left  in  position  for  a  few  clays.  The  wound  usually 
heals  kindly,  but  the  operation  may  have  to  be  repeated 
for  a  second  crop  of  warty  growths. 

FOREIGN  BODIES  IN  THE  AIR  PASSAGES.38 

The  presence  of  a  foreign  body  in  the  air  passages  is 
always  a  matter  of  interest  both  to  the  physician  and  to 
the  surgeon  :  to  the  physician  on  account  of  the  subtlety 
of  its  exact  localisation,  and  to  the  surgeon  because  of 
the  difficulties  connected  with  its  removal. 

The  foreign  body  is  usually  sucked  into  the  air  passages 
by  a  sudden  and  deep  inspiration,  but  it  may  gain  access 
to  the  respiratory  tract  by  the  child  going  to  sleep  with 
some  small  object  in  its  mouth.  The  foreign  bodies  in 
children  are  usually  parts  of  toys,  beads,  cherry-stones,  and 
other  substances  of  a  similar  nature.  Such  coins  as  they 
are  likely  to  have,  and  larger  objects,  like  marbles,  usually 
find  their  way  into  the  oesophagus,  as  the  rima  glottidis 
is  too  small  to  receive  them,  and  foreign  bodies  are  there- 
fore much  more  frequent  in  the  oesophagus  of  children 
than  in  their  tracheas. 

Symptoms.  —  The  symptoms  vary  according  to  the 
position  of  the  body.  They  are  sometimes  urgent,  as  in 
those  cases  in  which  the  foreign  body  lies  in  the  glottis  ; 
but  they  are  often  so  slight  as  to  make  it  a  matter  of 
doubt  whether  so  serious  an  accident  has  really  happened 
to  the  child.  The  cases  attended  with  the  slighter  initial 
symptoms  are  usually  the  most  to  be  dreaded,  for  the 
foreign  body  has  then  left  the  trachea,  and  passed  into  a 
bronchus,  where  it  may  become  impacted,  and  where  it  will 
most  probably  set  up  a  dangerous  pneumonia,  or  if  the 
bronchial  obstruction  is  complete  it  will  certainly  cause 
collapse  of  the  lung. 

The   examination  in  all  suspected  cases  must  be  con- 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  363 

ducted  with  the  greatest  care  and  precision.  When  the 
body  is  lying  in  the  trachea,  there  is  no  difficulty  in  re- 
cognising its  pres  >nce  :  but  if  it  has  become  impacted  in  a 
bronchus,  the  chil  1  must  be  stripped  to  ascertain  whether 
the  two  sides  of  the  chest  are  equally  movable.  Careful 
percussion  may  detect  the  presence  of  local  impairment  of 
resonance,  marking  the  collapsed  portion  of  the  lung  and  so 
the  approximate  position  of  the  occluding  body.  Auscul- 
tation will  confirm  the  evidence  gained  from  percussion  by 
the  absence  of  breathing  sounds  over  the  affected  area  and 
its  exaggeration  upon  the  opposite  side  of  the  chest  when 
there  is  complete  blocking  of  a  large  bronchus,  or  by  super- 
added sounds  if  the  bronchus  be  only  partially  obstructed. 
There  may  be  no  dyspnoea,  but  the  respirations  are  often 
considerably  quickened,  and  there  may  be  a  short  cough 
when  any  muscular  exertion  is  made.  The  temperature 
may  remain  subnormal,  unless  the  foreign  body  is  septic  ; 
but  in  several  cases  a  sharp  attack  of  fever  has  followed 
the  removal  of  the  body. 

Prognosis. — The  prognosis  is  so  serious  that  an  opera- 
tion must  be  performed  as  soon  as  the  presence  of  the  body 
is  found  to  be  interfering  with  the  respiratory  functions, 
even  in  the  absence  of  urgent  symptoms,  for  spontaneous 
expulsion  is  of  very  rare  occurrence.  Mr.  Good,38  however, 
records  an  interesting  case  in  which  a  "  hale  of  barley'' 
passed  from  the  trachea  into  the  axilla,  and  was  discharged 
by  means  of  an  abscess  a  fortnight  later.  Deoth  usually 
takes  place  from  oedema  of  the  glottis,  from  ulceration  of 
the  larynx,  from  pneumonia,  or  from  gangrene  of  the  lung. 

Treatment. — Tracheotomy  offers  the  only  means  of 
treatment  which  is  likely  to  be  of  any  avail.  A  large 
opening  should  be  made  in  the  trachea,  preferably  below  the 
isthmus  of  the  thyroid;  and  Mr.  Thos.  Smith38  suggests  that 
the  edges  of  the  wound  in  the  trachea  slioul  1  bo  tempora- 


364     -THE    SURGICAL    DISEASES    OF    CHILDREN 

rily  attached  to  the  skin  whilst  searching  for  foreign  bodies 
in  the  air  passages  below.  It  keeps  the  trachea  widely 
open  throughout  the  operation,  and  this  is  a  great  help  to 
the  surgeon,  and  a  source  of  safety  to  the  patient.  The 
trachea  should  be  held  widely  open  if  the  foreign  body  is 
known  to  be  lying  in  its  lumen,  for  it  often  happens  that 
the  first  blast  of  air  carries  it  out  of  the  wound ;  but  if  it 
be  impacted  in  one  of  the  bronchi,  it  must  first  be  localised 
by  means  of  a  probe,  and  an  endeavour  must  be  made  to 
withdraw  it  by  forceps.  The  greatest  gentleness  is  needed 
in  these  manipulations,  or  much  injury  may  be  done  to  the 
lung. 

The  wound  should  be  closed  at  once  if  the  foreign  body 
can  be  extracted  ;  but  if,  unfortunately,  this  is  found  to  be 
impossible,  the  wound  must  be  left  open  with  a  self-retain- 
ing spring  retractor  in  the  trachea  in  place  of  a  tracheo- 
tomy tube. 

The  following  instructive  case  shows  the  utility  of  this 
precaution  ;  the  specimen  is  in  the  Museum  of  St.  Bartho- 
lomew's Hospital.  A  little  girl,  aged  seven  years,  swal- 
lowed a  glass  bead,  which  "  went  the  wrong  way."  The 
bead  could  be  heard,  by  means  of  a  stethoscope,  passing 
up  and  down  the  trachea  between  its  bifurcation  and  the 
larynx  at  each  inspiration,  and  it  was  decided  to  perform 
a  tracheotomy.  Just  before  the  operation  was  commenced, 
it  was  found  that  the  movements  of  the  bead  could  no 
longer  be  heard  ;  and  as  it  was  supposed  to  have  passed 
into  the  pharynx,  and  to  have  been  swallowed,  the  opera- 
tion was  postponed.  Two  days  later  no  breathing  sounds 
were  audible  in  the  right  lung,  and  the  heart  had  become 
displaced  to  the  right,  showing  that  the  lung  on  this  side 
had  become  collapsed.  Tracheotomy  was  performed  ;  and 
although  the  chill  was  inverted  whilst  the  wound  was 
held  open,  and  feathers  were  passed  down  the  trachea,  the 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  365 

bead  could  not  be  dislodged ;  a  tracheotomy  tube  was  in- 
serted, and  the  child  was  put  to  bed.  She  had  a  violent 
attack  of  dyspnoea  during  the  night,  the  tube  was  with- 
drawn, and  the  bead  was  immediately  coughed  i;p.  She 
made  a  good  recovery.  The  after-treatment  in  these  cases 
is  the  same  as  after  the  ordinary  tracheotomy  operation 
(p.  351). 

HERNIA   OF   THE  PLEURA  INTO   THE  NECK. 

A  few  examples  of  this  rare  condition  have  been  recorded. 
It  seems  to  be  most  frequently  caused  by  the  rupture  of  a 
bronchus  in  the  upper  bbe  of  a  lung  which  strips  the 
pleura  from  the  lung.  In  a  case  seen  by  Dr.  Fowler,  a 
child  of  three  months  old,  who  had  recently  suffered  from 
a  severe  attack  of  bronchitis,  presented  a  swelling  upon 
the  side  of  the  neck,  which  became  larger  when  the  cliil  1 
cried  or  coughed,  but  which  almost  disappeared  at  each 
inspiration.  In  this  case  the  rupture  had  occurred  in 
both  lungs,  but  the  tumour  was  larger  upon  the  left  side. 

HERNIA  OF  THE   LUNG. 

A  portion  of  the  lung  is  occasionally  protruded  through 
some  part  of  the  chest-wall  as  a  sequel  of  an  injury  to  the 
thorax.  It  forms  a  smooth  tumour,  which  is  resonant  on 
percussion  and  can  be  reduced  by  pressure. 

Treatment. — The  treatment  consists  in  the  application 
of  a  pad  and  bandage  over  the  affected  part.  If  the  swell- 
ing increases  in  size,  it  may  be  removed,  for  wounds  of  the 
lung  heal  very  readily  and  completely  in  children. 

EMPYEMA.-1 

jffitiology.  Empyema  is  a  condition  often  met  with  in 
children  after  an  attack  of  pneumonia ;  less  frequently  it 
occurs  as  a  primary  disease,  acute  in  its  onset.     It  is  rarely 


366      THE    SURGICAL    DISEASES    OF    CHILDREN 

tuberculous  or  traumatic  in  origin.  It  is  said  to  be  most 
frequently  associated  with  the  presence  of  pneumococci, 
though  other  forms  of  micro-organisms,  including  the 
bacillus  coli,  are  very  common  ;  cases,  however,  often  occur 
in  which  no  specific  organism  can  be  detected. 

Symptoms. — The  less  common  primary  form  begins 
with  a  convulsion  or  with  vomiting.  In  all  acute  diseases, 
however,  convulsions  are  very  much  mora  common  in  infants 
than  rigors,  so  that  the  diagnostic  value  of  a  convulsion  is 
not  great.  The  temperature  rises  rapidly  to  104°- 105  F. 
The  respirations  are  short,  quick,  and  of  the  abdominal 
type.  The  pulse  may  be  140  or  more  in  a  minute.  Cough, 
which  is  absent  in  the  earlier  stages,  afterwards  becomes 
dry  and  hacking.  The  dyspnoea  is  often  urgent,  and  the 
child  is  with  difficulty  kept  in  bed.  The  duration  of  the 
acute  attack  is  generally  from  seven  to  ten  days,  after 
which  the  temperature  falls,  but  does  not  become  normal. 
An  empyema  may  be  suspected  when  the  child  remains 
weak  and  continues  to  lose  flesh,  the  cough  persisting,  and 
convalescence  being  retarded.  The  form  is  often  due  to  a 
pure  cultivation  of  the  pneumococcus,  and  it  can  be  cured 
sometimes  by  a  single  aspiration  of  the  pleural  cavity. 

The  subacute  form,  secondary  to  pleurisy  with  effusion, 
pneumonia,  typhoid  fever,  and  more  rarely  to  tuberculous 
phthisis,  is  often  so  insidious  in  its  onset  that  the  presence 
of  pus,  even  in  considerable  quantities,  may  be  completely 
overlooked.  The  long  continuance  of  pulmonary  symptoms, 
with  a  persistent  rise  of  temperature,  and  the  occurrence  of 
dyspnoea,  rigors,  sweats  and  localised  pain  in  a  child  who 
has  recently  recovered  from  one  of  these  diseases,  always 
raises  a  suspicion  that  pus  exists  in  the  thoracic  cavity, 
and  affords  an  indication  for  an  exploratory  puncture.  It 
is  due  to  a  mixed  cultivation  containing  pyogenic  organ- 
isms. 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  367 

Dr.  Dickinson  has  recently  called  attention  to  the  com- 
parative readiness  with  which  the  pleura  suppurates  in 
early  life,  so  that  what  in  a  grown  person  would  be  a  dry 
pleurisy  or  a  serous  effusion  gives  rise  to  an  empyema  in 
a  child. 

The  physical  examination  of  the  chest  in  a  case  of 
empyema  will  show  that  one  side  is  motionless,  and  will 
reveal  the  existence  of  extensive  dulness,  a  condition  which 
is  rare  in  the  pneumonia  of  children.  The  dulness,  how- 
ever, is  not  always  easy  to  elicit ;  but  percussion  gives  a 
sense  of  wooden  resistance  which  is  characteristic  in  chil- 
dren, for  in  them  it  is  a  rule  to  find  resilient  chest-walls. 
The  apex-beat  of  the  heart  is  sometimes  found  to  be  dis- 
placed ;  but  this  is  less  common  in  children  than  in  the 
empyema  of  adults.  The  breathing  sounds  are  absent,  or 
distant  bronchial  breathing,  which  may  closely  resemble 
tubular  breathing,  may  be  heard.  Dr.  Brothers  has  pointed 
out  that  the  absence  of  rales  in  a  child  who  otherwise 
presents  symptoms  of  chronic  lung  disease  is  also  very 
suggestive  of  pleural  effusion  ;  and  if  rales  are  heard  all 
over  the  chest,  except  at  a  single  spot,  it  is  probable  that 
there  is  a  localised  empyema.  Many  physicians  have  laid 
stress  upon  the  fact  that  bulging  of  the  lower  intercostal 
spaces  is  observed  in  cases  of  empyema;  but  although  the 
sign  is  a  valuable  one,  it  is  by  no  means  pathognomonic  of 
the  affection.  There  is  often  more  or  less  lateral  curvature 
in  cases  of  long-standing  empyema,  the  concavity  of  the 
spinal  curve  being  directed  towards  the  affected  side, 
whilst  the  angles  of  the  ribs  become  flattened,  those  on  the 
sound  side  becoming  more  acute.  There  is  also  some  rota- 
tion of  the  bodies  of  the  vertebrae,  but  it  is  usually  less 
marked  than  in  the  ordinary  cases  of  scoliosis. 

Diagnosis. — The  diagnosis  is  readily  confirmed  by 
puncturing  the  chest  with  an  aspirating  needle,  and  two 


368      THE    SURGICAL    DISEASES    OF    CHILDREN 

important  facts  will  thereby  be  ascertained  :  first,  whether 
fluid  be  present  at  all ;  and  secondly,  if  it  be  present, 
whether  it  is  serous  or  purulent.  The  existence  of  an 
abscess  in  the  lung  may  sometimes  be  detected  by  punc- 
ture, and  it  may  then  be  mistaken  for  an  empyema. 
Several  things  have  to  be  taken  into  consideration  in 
aspirating  a  chest.  The  operation,  trivial  as  it  is,  must 
be  carried  out  with  strict  asepsis,  lest  a  serous  effusion 
be  converted  into  a  purulent  one.  The  side  of  the  chest 
must  be  therefore  thoroughly  cleansed,  the  needle  must  be 
freshly  boiled,  and  the  skin  should  be  incised  with  a 
scalpel,  so  that  no  dirty  epithelial  scale  be  carried  into 
the  pleural  cavity. 

Prognosis. — The  rate  of  mortality  in  empyema  seems 
to  bear  a  direct  relation  to  the  age  of  the  child.  Dr. 
Brothers,  in  an  interesting  paper,  shows  that  in  very  young 
children,  in  whom  the  disease  always  runs  a  severe  course, 
the  rate  of  mortality  is  nearly  50  per  cent.,  and  that  it 
gradually  diminishes,  until  after  the  age  of  five  years  it  is 
almost  nil- 
Treatment. — Aspiration  should  be  performed  in  the 
sixth  or  seventh  intercostal  space  in  the  mid-axillary  line, 
or  behind  in  the  seventh  or  eighth  interspace  at  the  junc- 
tion of  the  anterior  two  thirds  with  the  posterior  third 
of  the  rib.  When  an  empyema  opens  spontaneously,  it 
usually  points  anteriorly  about  the  junction  of  the  fifth 
or  sixth  costo-chondral  articulation.  Two  mistakes  may 
be  made  in  performing  an  exploratory  paracentesis :  the 
needle  may  be  too  short  to  pass  through  the  tough  and 
thickened  pleura,  or  owing  to  its  gristly  nature  the  needle 
may  fail  to  penetrate  it,  and  thus  false  information  is  ob- 
tained. The  empyema  may  be  localised,  so  that  a  single 
puncture  may  be  insufficient. 

(1)  Drainage. — When  pus  is  found,  it  is  better  to  draw 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  369 

it  all  off,  f~>r  simple  aspiration  more  frequently  cures  in 
chiLlhood  than  in  adult  age.  If  mnre  pus  is  formed,  it  is 
better  to  drain  the  cavity  at  once  rather  than  to  trust  to 
repeated  aspiration.  Even  in  the  most  acute  cases,  how- 
ever, pus  is  not  found  before  the  third  day,  and  usually 
not  until  after  the  sixth  day  from  the  initial  symptoms. 
The  intercostal  spaces  in  children  are  so  narrow  that  a 
thorough  drainage  can  only  be  effected  by  removing  a  piece 
of  rib  or  grooving  two  ribs  so  as  to  allow  of  the  intro- 
duction of  a  good-sized  tube.  Mr.  Pantin,  my  house-sur- 
geon at  the  Victoria  Hospital,  has  kindly  given  me  the 
following  account  of  the  routine  treatment  which  he  and 
his  colleagues  adopt  in  cases  of  empyema ;  and  as  the 
resident  medical  officers  at  a  large  children's  hospital  have 
more  extensive  opportunities  of  treating  the  disease  than 
any  one,  I  here  append  it. 

"If  the  empyema  be  general,  and  the  dyspnoea  be  not 
very  urgent,  the  chest  is  opened  in  the  line  of  the  angle  of 
the  scapula  behind  ;  if  localised,  it  is  opened  at  its  most 
dependent  part.  When  the  dyspnoea  is  urgent,  aspiration 
may  have  to  be  performed  at  once,  the  more  severe  opera- 
tion being  temporarily  postponed.  An  exploring  needle 
is  always  put  in  just  above  or  below  the  piece  of  rib  it 
is  proposed  to  excise.  The  ninth  rib  is  generally  chosen 
for  removal  in  cases  of  general  empyema,  on  the  grounds 
recommended  by  Mr.  Godlee.  First,  because  it  is  just 
above  the  level  at  which  the  diaphragm  becomes  adherent 
to  the  ribs  when  it  has  been  drawn  up  as  much  as  possible  ; 
secondly,  because  it  is  the  most  dependent  part  whon  the 
patient  is  Lying  on  his  back  ;  and  thirdly,  because  it  is  the 
most  advantageous  place  for  draining  the  whole  of  the 
pleural  cavity,  including  its  lower  and  posterior  part, 
which  can  alone  be  drained  by  this  means.  An  incision  is 
made  over  the  rib,  about  2  or  2A   inches  in  length,  after 

1:  if 


37©      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  skin  has  been  thoroughly  cleansed.  The  incision  is 
deepened  by  cutting  through  the  latissimus  dorsi  and  the 
serratus  magnus  till  the  periosteum  is  reached.  This 
membrane  is  divided  along  the  whole  length  of  the  wound, 
and  is  then  stripped  off  the  rib  with  a  blunt  dissector, 
until  the  bone  is  bare  in  front  and  behind.  Bone  forceps 
are  applied,  and  about  an  inch  of  the  rib  is  removed,  the 
anterior  cut  being  made  first.  The  ends  of  the  bone  are 
rounded  off  with  a  burr  or  raspatory.  The  operation  so 
far  is  entirely  extra-pleural.  The  pleural  cavity  is  opened 
either  by  introducing  a  director,  and  dilating  the  opening 
with  dressing  forceps,  or,  if  the  pleura  is  too  thick  and 
gristly,  by  carefully  cutting  through  it  with  a  knife  and 
afterwards  using  the  finger  as  a  dilator.  The  patient  is 
now  turned  over  upon  his  back  to  allow  the  fluid  to  escape, 
and  any  large  masses  of  lymph  are  delivered  with  the 
finger.  The  cavity  is  never  washed  out  with  aseptic 
water  or  lotion,  unless  its  contents  are  very  foetid. 

"  A  stout,  short-flanged  drainage-tube  of  rubber  (fig.  40) 
is  inserted,  so  that  the  cavity  may  be  freely  drained  with- 
out any  pressure  of  the  tube  upon  the  expanding  lung. 
The  tube,  which  is  easily  made  out  of  two  pieces  of 
drainage-tube,  is  not  sewn  in,  but  is  removed  and  cleaned 
at  each  dressing.  A  pad  of  wet  cyanide  gauze,  moistened 
with  boric  lotion,  is  then  applied,  and  the  child  is  put  to 
bed.  The  dressing  usually  has  to  be  renewed  within 
twelve  hours,  and  after  that  daily.  Smaller  and  smaller 
tubes  are  substituted,  as  the  discharge  gradually  decreases 
in  quantity,  and  eventually  the  tube  is  omitted  altogether. 

"  New  bone  appears  to  be  produced  very  rapidly,  for  in 
one  case,  which  died  a  few  weeks  after  the  wound  had 
closed,  the  rib  was  found  to  be  completely  repaired. 

"  We  have  on  an  average  one  case  a  fortnight  to  treat  in 
this  manner,  and  the  results  are  eminently  satisfactory. 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  37 1 


The  average  stay  of  the  children  in  the  Hospital  has  been 
six  weeks.  When  death  occurs,  it  is  due  to  nephritis, 
broncho-pneumonia,  and  general  tuberculosis."  There  is 
often  some  lateral  curvature  of  the  spine  in  cases  of  cured 
empyema  ;  this  is  best  treated  by  gymnastics  rather  than 
by  the  application  of  any  form  of  spinal  support. 

(2)  Operation  for  Radical  Cure. — When  the  sinuses 
refuse  to  close,  adhesions  are  present,  and  the  lung  does 
not  expand,  it  is  often  necessary  to  resect  several  ribs  so 
as  to  enable  the  chest  to  collapse  upon  the  affected  side, 


Fig.  40.— Short-flanged  rubber  tube  for  draining  the  pleural  cavity  incases 
of  empyema. 

the  constant  purulent  discharge  is  then  arrested  by  allow- 
ing the  parietal  and  visceral  layers  of  the  pleura  to  become 
approximated.  The  operation  should  not  be  undertaken 
lightly,  for  it  leads  to  marked  deformity  ;  but,  on  the  other 
hand,  it  should  not  be  unduly  postponed  in  the  cases  which 
need  it,  for  the  prolonged  hectic  may  lead  to  the  child's 
destruction  by  lardaceous  disease.  The  fourth,  fifth,  and 
sixth  ribs  are  usually  selected  for  removal.  Tho  operation 
is  similar  to  that  already  described  (p.  369),  except  that 
•Jonger  pieces  of  bone  are  removed,  and  the  incision  is  made 


372      THE    SURGICAL    DISEASES    OF    CHILDREN 

along  the  intercostal  space  and  not  upon  the  rib  itself,  so 
that  two  ribs  may  be  removed  through  each  incision.  The 
finger  is  introduced  into  the  cavity  of  the  pleura,  and  so 
much  and  so  many  of  the  ribs  are  removed  as  is  necessary 
to  enable  it  to  become  occluded.  The  mistake  usually 
made  is  to  remove  too  little  bone  in  these  cases  rather  than 
too  much,  for  the  thoracic  walls  have  very  great  power  of 
repair.  It  is  therefore  better  to  remove  the  periosteum 
and  the  thickened  pleura,  and  this  can  usually  be  done 
without  much  bleeding,  as  the  previous  inflammation  has 
occluded  the  intercostal  vessels.  The  number  of  ribs  to 
be  removed  is  regulated  by  the  size  of  the  cavity  ;  and  it 
was  the  recognition  of  this  fact  which  led  Estlander  to 
make  that  important  advance  in  the  surgery  of  the  chest 
which  has  just  been  described,  so  that  the  operation  of 
resection  of  the  ribs  for  the  cure  of  empyema  is  now 
generally  known  by  his  name. 

Treatment  of  Double  Empyema. — The  operative 
treatment  of  double  empyema  has  recently  been  the  subject 
of  much  careful  thought  by  surgeons  and  physicians  in 
this  country.  The  conclusions  arrived  at  by  Dr.  Coupland 
and  Mr.  Pearce  Gould  appear  to  represent  most  accurately 
the  general  feeling  upon  this  point.  They  say  {Trans. 
Clinical  Soc,  vol.  xxiv.  p.  83)  :  (1)  That  the  occurrence 
of  double  empyema,  instead  of  being  a  bar  to  treatment  by 
drainage,  renders  the  need  for  such  an  operation  more 
urgent  on  account  of  the  greater  embarrassment  it  causes 
to  respiration  and  circulation.  (2)  That  aspiration  should 
be  practised  as  a  preliminary  procedure,  in  the  hope  that 
at  any  rate  some  contraction  of  the  abscess  cavities  may 
result  from  it  and  further  adhesions  of  the  pleura  form. 
(3)  That  it  is  better  to  allow  a  few  days  to  elapse  between 
the  two  operations ;  and  (4)  that  if  this  delay  is  for  any 
reason  impossible,  the  two  empyemata  should  be  carefully 


SURGICAL    DISEASES    OF    THE    AIR    PASSAGES  2,73 

aspirated  a  few  hours  before  the  operation.  By  this  means 
the  shock  produced  by  the  sudden  removal  of  pressure 
from  the  lungs  is  got  over,  and  the  simultaneous  drainage 
of  the  two  pleurae  is  robbed  of  its  chief  danger.  (5)  That 
double  empyema  treated  by  free  drainage  may  be  followed 
in  children  by  very  complete  recovery.  The  condition  is 
a  rare  one,  and  no  case  has  yet  come  under  my  notice ;  but 
when  it  does  I  shall  have  no  hesitation  in  following  the 
advice  given  by  Dr.  Coupland  and  Mr.  Gould. 

Pleurisy. 

Cases  of  pleurisy  with  effusion  rarely  come  under  the 
care  of  the  surgeon,  since  a  single  aspiration  is  often 
sufficient  to  cure  those  children  who  do  not  recover  under 
the  ordinary  medical  treatment  of  rest  and  counter-irrita- 
tion of  the  chest-wall. 

PURULENT  PERICARDITIS.40 
Etiology. — Purulent  collections  in  the  pericardium  are 
either  primary  or  secondary  to  septic  infective  processes  in 
the  thorax  or  other  parts  of  the  body.  The  pneumococcus 
and  Friedliinder's  pneumo-bacillus  have  been  found  in  the 
pus. 

Symptoms. — It  occasionally  happens,  after  an  empyema 
has  been  evacuated,  that  the  temperature,  pulse  and  respi- 
rations remain  abnormally  high ;  the  dyspnoea  continues, 
and  the  child  does  not  experience  the  amount  of  relief 
which  usually  follows  the  operation.  A  careful  examina- 
tion of  the  chest  should  be  made  in  these  cases,  and  it 
may  then  be  found  that  there  is  some  oedema  of  the  neck, 
that  the  area  of  precordial  duluess  is  enlarged,  that  there 
is  an  intense  interscapular  souffle,  and  there  may  be  the 
physical  signs  pointing  to  a  pleural  effusion  at  the  base  of 
the  left  lung — signs  which  disappear  when  the  child  is 
examined  in  the   genu-pectoral  position.      These  pseudo- 


374      THE    SURGICAL    DISEASES    OF    CHILDREN 

pleuritic  symptoms  are  due  to  atelectasis  of  the  lower  lobe 
of  the  left  lung,  caused  by  the  pressure  exercised  upon  it 
by  the  pericardial  effusion ;  and  they  are  better  marked 
in  the  child  than  in  the  adult,  becaiise  the  child's  chest 
is  small  and  narrow,  whilst  its  heart  is  relatively  large. 
The  disappearance  of  the  signs  when  the  genu-pectoral 
position  is  adopted,  is  caused  by  the  pericardial  fluid  fall- 
ing forwards,  and  so  ceasing  to  exercise  any  pressure  upon 
the  lung.  This  symptom  is  of  course  valueless  if  the 
pericarditis  be  associated  with  broncho-pneumonia,  pneu- 
monia, or  pleurisy. 

Diagnosis. — The  presence  of  a  purulent  collection  in 
the  pericardium  is  very  easily  overlooked,  so  that  if  there 
is  the  least  suspicion  of  its  presence  an  exploratory  punc- 
ture should  be  made  with  a  trocar  and  canula  which 
have  been  freshly  boiled  to  render  them  aseptic.  The  side 
of  the  chest  must  be  thoroughly  cleansed,  and  the  skin 
should  be  divided  with  a  scalpel  to  prevent  any  chance 
epithelial  scale  being  driven  into  the  pericardium  at  the 
end  of  the  trocar.  The  incision  should  be  made  in  the 
fourth  or  fifth  intercostal  space  on  the  left  side  and  at  a 
point  about  an  inch  from  the  sternum,  to  avoid  injuring 
the  internal  mammary  artery. 

Treatment.  —  The  puncture  should  be  carefully  en- 
larged if  pus  appears — for  puncture  is  of  no  more  per- 
manent value  here  than  it  is  in  a  case  of  empyema — the 
tissues  being  divided  in  an  outward  direction  until  it 
escapes  freely.  The  wound  must  then  be  drained  in  the 
ordinary  way,  and  antiseptic  dressings  applied.  The 
cavity  of  the  pericardium  may  subsequently  be  washed 
out  daily  with  a  5  per  cent,  solution  of  boric  acid  at  a 
temperature  of  100°  F.  until  the  discharge  ceases.  Korte 
in  one  case  resected  the  left  fifth  rib  for  the  cure  of  a 
pericardial  empyema. 


CHAPTER  XVIII 

SURGICAL  AFFECTIONS  OF  THE  ABDOMEN 
AND  ITS  CONTENTS 

TUBERCULOUS  PERITONITIS.11 

iEtiology.  —  Tuberculous  peritonitis  occurs  very  fre- 
quently in  children,  the  direct  source  of  infection  most 
often  being  caseating  mesenteric  glands.  The  affection 
occurs  at  all  ages,  but  is  more  frequent  after  weaning  than 
in  sucklings — a  fact  which,  as  Prof.  McFadyean  and  Dr. 
Woodhead  have  acutely  pointed  out,  raises  a  suspicion 
that  the  use  of  tuberculous  milk  may  be  a  source  of  in- 
fection. Clinical  experience  has  not  yet  demonstrated  the 
correctness  of  this  view  ;  but  there  is  no  reason  why  we 
should  not  assume  that  it  is  correct,  and  boil  all  milk 
given  to  children.  It  is  an  easy  precaution,  for  a  single 
boiling  is  sufficient  to  destroy  its  infectivity;  but  if  it 
be  adopted,  the  infant  should  have  a  small  teaspoonful  of 
orange  juice  every  day,  as  there  is  reason  to  suppose  that 
suae  cases  of  scurvy  are  attributable  to  a  too  exclusive 
diet  of  such  sterile  font  Is. 

Morbid  Anatomy. — Tuberculous  peritonitis  occurs  in 
several  forms.  There  is  the  acute  miliary  type  of  tin' 
disease,  for  which  little  or  nothing  can  be  done  in  the 
way  of  operative  treatment,  and  to  which  the  child  soon 
succumbs.  It  is  marked  by  the  frequency  with  which 
relapses    take   place.      The   ascitic    type,    in    which    the 


1 


J6      THE    SURGICAL    DISEASES    OF    CHILDREN 


exudation  is  serous,  the  result  of  a  simple  infection  with 
the  tubercle  bacillus,  or  purulent,  when  the  infection  is  a 
mixed  one  consisting  partly  of  the  tubercle  bacillus  and 
partly  of  septic  micro-organisms.  This  type  is  amenable 
to  operative  treatment,  as  was  shown  accidentally  by  Sir 
Spencer  Wells  in  1862,  and  deliberately  by  Koenig  in 
1884.  The  fibroplastic  type  differs  from  the  preceding  in 
its  extremely  chronic  course,  and  in  the  readiness  with 
which  adhesions  are  formed.  It  is  accompanied  by  more 
or  less  ascites,  and  is  characterised  by  the  readiness  .with 
which  dense  adhesions  are  formed.  Lastly,  there  is  the 
ulcerative  type,  which  is  a  very  frequent  and  fatal  form 
in  children.  The  inflammatory  products  in  this  variety 
soften  and  ulcerate,  so  that  on  opening  the  abdomen  a 
shapeless  mass  of  material  is  found,  all  the  structures 
being  glued  together  and  to  the  abdominal  wall  by  inflam- 
matory exudation.  It  is  not  unusual  in  these  cases  to  get 
a  fsecal  fistula  at  the  umbilicus.  This  ulcerating  form  of 
tuberculous  peritonitis  is  unsuited  for  operative  treatment. 

Symptoms. — The  symptoms  of  the  disease  vary  some- 
what with  the  form,  and  though  it  is  usually  easy  to 
diagnose,  the  symptoms  are  sometimes  so  obscure  that 
many  laparotomies  have  been  performed  to  relieve  an  acute 
intestinal  obstruction  only  to  find  that  the  peritoneal  cav- 
ity was  full  of  pus.  The  classical  symptoms  of  pain  in 
the  abdomen,  with  quick  breathing,  anxious  expression, 
tympanitic  and  tender  belly,  are  sometimes  found  in  cases 
of  acute  miliary  tuberculosis ;  but  the  symptoms  are 
usually  more  ill-defined.  There  is  abdominal  pain  with 
fever,  better  marked  in  the  afternoon  and  evening  than 
in  the  morning.  The  bowels  are  relaxed,  and  there  are 
occasional  attacks  of  diarrhoea. 

The  abdomen  in  the  ascitic  forms  gradually  enlarges 
until  it  is  rounded  and  shiny,  with  many  large  dilated  veins 


SURGICAL    AFFECTIONS    OF    THE    ABDOMEN       2)77 

on  its  surface.  It  is  resonant  in  front,  and  dull  upon  per- 
cussion in  the  flanks,  the  line  of  dulness  altering  with  the 
position  of  the  patient.  The  abdomen  sometimes  feels 
nodular,  and  in  the  cases  of  localised  effusion  the  cysts  are 
easily  detected  if,  as  usually  happens,  they  are  situated 
above  the  umbilicus.  The  disease  in  the  fibrous  form 
lasts  months  or  years,  and  tends  to  undergo  spontaneous 
recovery,  though  it  may  cause  many  sequelae,  due  to  the 
bands  of  adhesion.  The  patient  in  the  other  forms  becomes 
anaemic  and  wasted ;  he  is  the  subject  of  hectic  fever  and 
of  lardaceous  disease,  unless  he  dies  of  the  exhaustion  pro- 
duced by  diarrhoea  or  from  tuberculous  meningitis. 

Sequelae. — The  sequelae  of  tuberculous  peritonitis  are 
recurrences  due  to  persistence  of  the  source  of  infection  : 
faecal  fistulas,  the  result  of  the  inflammation  spreading  ii  - 
wards  through  the  bowel  wall,  or  more  rarely,  outwards 
from  tuberculous  ulceration  of  the  intestine.  These  fis- 
tulas most  often  discharge  themselves  at  the  umbilicus,  in 
the  unopened  abdomen  ;  but  if  a  laparotomy  has  been  per- 
formed, they  may  appear  at  the  scar.  They  sometimes 
close  spontaneously,  but  they  often  cause  death  by  setting 
up  an  acute  septic  peritonitis.  Intestinal  obstruction  in 
its  various  forms  is  not  an  infrequent  result  of  cured 
tuberculous  peritonitis. 

Diagnosis. — The  differential  diagnosis  lies  between 
tuberculous  and  other  forms  of  peritonitis,  as  well  as  of 
the  various  conditions  which  render  laparotomy  necessary, 
and  from  some  cases  of  typhoid  fever.  The  exact  nature 
of  the  abdominal  lesion  is  always  a  matter  of  doubt,  and  it 
is  this  uncertainty  which  lends  so  great  an  interest  to 
every  case  of  abdominal  section.  Tuberculous  peritonitis 
may  be  distinguished  from  the  non-tuberculous  forms  by 
bacteriological  examination,  or  by  inoculation  into  guinea- 
pigs  of  the  inflammatory  contents  of  the  peritoneum — a 


1 


78      THE    SURGICAL    DISEASES    OF    CHILDREN 


method  not  permissible  in  this  country.  The  differential 
diagnosis  is  sometimes  spontaneously  made  for  us,  as  in 
those  cases  where  about  a  fortnight  or  three  weeks  after 
the  operation,  and  when  the  wound  has  completely  healed, 
the  scar  becomes  affected  with  tuberculous  inflammation. 
I  have  several  times  seen  such  secondary  infection  happen  ; 
the  ulcerated  skin  was  freely  removed,  and  in  each  case 
there  was  no  further  recurrence. 

Treatment. — The  ordinary  palliative  means  must  be 
first  tried,  but  if  these  fail  laparotomy  yields  the  most  satis- 
factory results  in  cases  of  tuberculous  peritonitis  which 
have  been  selected  with  moderate  care.  Children  bear  the 
operation  well,  and  it  appears  to  be  especially  adapted  for 
the  ascitic  forms,  and  for  the  chronic  fibrous  type  associated 
with  much  exudation.  In  the  latter  form  the  simple  open- 
ing of  the  abdomen,  and  evacuation  of  the  fluid  without 
flushing  the  peritoneal  cavity,  gives  the  best  results.  Strict 
asepsis  must  be  preserved  by  the  ordinary  methods,  and 
the  bowel  may  be  disinfected  internally  by  the  adminis- 
tration of  naphthol  or  naphthaline  (p.  319)  after  the  ad- 
ministration of  a  drachm  of  castor  oil,  though  this  is  of  less 
importance  than  in  cases  of  septic  peritonitis  due  to  the 
bacillus  coli. 

The  incision  in  the  ordinary  ascitic  cases  should  be  made 
below  the  umbilicus,  care  being  taken  not  to  wound  the 
bowel  or  omentum,  for  they  are  often  adherent  to  the 
peritoneum  ;  not  to  injure  the  bladder,  which  may  extend 
higher  than  is  expected ;  and  not  to  work  too  cautiously 
by  dissecting  with  undue  care  through  the  thickened 
subperitoneal  fat  and  peritoneum.  These  tissues  in  chronic 
cases  are  sometimes  so  greatly  thickened  that  they  may 
be  mistaken  for  the  omentum  ;  and  an  extensive  dissection, 
by  opening  different  layers  of  tissue,  militates  against 
rapid  healing  of  the  wound.      The  peritoneum  should  be 


SURGICAL    AFFECTIONS    OF    THE    ABDOMEN       379 

cautiously  pricked  with  a  scalpel  after  it  has  been  raised 
by  forceps,  and  the  incision  should  be  enlarged  with  blunt- 
pointed  scissors  to  the  full  extent  of  the  wound,  the 
fingers  being  used  as  directors  to  prevent  injury  to  the 
bowel.  All  fluid  should  be  evacuated,  but  the  adhesions 
must  be  treated  according  to  the  individual  case.  The 
only  general  rule  which  can  be  laid  down  is  that  they 
must  be  treated  as  tenderly  as  possible,  and  no  more  should 
be  done  to  them  than  is  absolutely  necessary.  If  the 
omentum  is  not  adherent  to  the  intestine,  and  is  much 
infiltrated  with  tubercle,  it  may  sometimes  be  removed 
with  advantage  ;  but  it  is  often  extremely  difficult  to  stop 
the  bleeding  when  this  has  been  done,  as  the  tissue  is  too 
soft  to  take  a  ligature. 

The  abdominal  cavity  may  be  flushed  with  sterilised 
water,  a  saturated  solution  of  boric  acid,  a  3  per  cent. 
solution  of  salicylic  acid,  or  a  0*6  per  cent,  of  common  salt 
when  the  peritoneal  fluid  is  purulent ;  if  it  be  serous,  it  is 
better  not  to  flush  at  all.  The  flushing  must  be  done  with 
the  greatest  care,  and  the  stream  should  be  full  and  gentle, 
rather  than  under  high  pressure,  and  delivered  through  a 
small  nozzle.  Its  temperature  should  be  10U-1050  F.  The 
wound  must  be  closed  at  once  in  the  simple  forms,  the 
edges  of  the  peritoneum  being  brought  together  by  a  row  of 
aseptic  catgut  sutures,  whilst  two  or  three  sutures  of  silver 
wire  are  passed  through  the  skin  and  muscular  walls  of  the 
alrlomen.  Secondary  sutures  of  horsehair  are  employed  to 
complete  the  closure  of  the  wound.  The  ordinary  dressings 
are  then  applied,  and  primary  union  is  the  rule.  The 
sutures  in  the  skin  should  be  removed  about  the  seventh  to 
the  tenth  day.  It  is  important  that  the  deep  as  well  as  the 
superficial  parts  of  the  wound  should  be  brought  into  good 
apposition,  for  there  is  a  tendency  after  these  operations 
towards    the   formation  of    a  ventral   hernia,  and,  to  still 


380      THE    SURGICAL    DISEASES    OF    CHILDREN 

further  obviate  this  tendency,  a  belt  should  be  worn  for  a 
considerable  length  of  time. 

Drainage  of  the  abdominal  cavity  is  as  far  as  possible 
to  be  avoided,  as  it  leads  to  the  formation  of  adhesions  ; 
but  it  must  be  adopted  when  the  fluid  is  purulent.  I  am 
in  the  habit  of  putting  a  stout  drainage-tube  into  the 
abdominal  cavity  in  purulent  cases  at  the  time  of  the 
operation,  closing  as  much  of  the  wound  as  possible,  and 
of  removing  the  tube  as  soon  as  the  discharge  has 
diminished,  usually  in  the  course  of  two  or  three  days, 
for  the  track  of  the  tube  is  rapidly  circumscribed  by 
granulation  tissue.  The  incision  is  made  directly  over 
the  swelling,  in  the  encysted  forms  of  the  disease,  the 
contents  are  evacuated,  and  the  wound  is  closed  at  once. 
It  appears  that  fistulse  are  rather  more  frequent  in  the 
localised  than  in  the  more  diffuse  forms  of  tuberculous 
peritonitis.  It  should  be  remembered  that  in  some  cases 
of  localised  abscess  the  collection  of  pus  is  not  always 
visible  as  soon  as  the  abdomen  is  opened,  as  it  may  be  con- 
cealed by  the  adhesion  of  two  loops  of  intestine,  so  that 
careful  search  may  be  necessary  to  expose  it. 

After-Treatment.— The  after-treatment  upon  which 
much  of  the  success  of  the  operation  depends,  consists  in 
keeping  the  patient  quiet,  but  not  necessarily  motionless,  in 
bed,  and  in  a  room  whose  temperature  is  maintained  at 
65°  F.  Small  doses  of  opium  may  be  given  for  the  first 
day  or  two  after  the  operation,  if  there  be  much  pain :  if 
the  temperature  rises,  and  enemata  fail  to  act,  a  little 
magnesia  or  half  a  grain  of  calomel  will  often  reduce  it. 
The  food  should  be  given  in  a  concentrated  form,  and  it 
may  often  be  peptonised  with  advantage. 

Contra-Indications  of  Operation.— Laparotomy  is 
contra-indicated  in  cases  where  the  abdomen  is  shrunken 
instead  of  being  distended ;  where  the  disease  is  of   the 


SURGICAL   AFFECTIONS    OF    THE    ABDOMEN      38 1 

acute  miliary  type,  and  where  rapid  caseation  or  ulceration 
is  taking  place ;  where  the  peritonitis  is  only  one  manifes- 
tation of  a  general  tuberculosis,  and  where  it  is  associated 
with  advanced  pulmonary  disease.  Albuminuria  due  to 
tuberculous  nephritis,  and  tuberculous  inflammation  of  the 
bowels  marked  by  melsena  and  diarrhoea,  although  they 
do  not  absolutely  forbid  the  operation,  are  such  serious 
complications  that  I  do  not  myself  perform  laparotomy  in 
these  cases,  unless  there  is  some  urgent  necessity  for  so 
doing.  I  do  not  hesitate,  on  the  other  hand,  to  open  the 
abdomen  in  the  fibrous  form  of  tuberculous  peritonitis  in 
which  there  is  only  slight  effusion  ;  in  those  cases  in  which 
the  convalescence  is  protracted,  and  the  patient  is  daily 
losing  flesh  ;  where  the  pain  is  sufficent  to  prevent  him 
following  his  usual  avocations;  or  where  he  has  insuperable 
constipation  apparently  depending  upon  the  presence  of  a 
constricting  band  low  down  in  the  abdominal  cavity. 

We  are  ignorant  of  the  mode  in  which  laparotomy  cures 
these  cases  of  tuberculous  peritonitis,  though  there  is  no 
doubt  that  it  does  so,  sometimes  permanently,  but  some- 
times only  in  part,  for  relapses  occur,  due  to  fresh  in- 
fection. Cases  of  relapse,  in  which  a  second  or  even  a 
third  laparotomy  has  had  to  be  performed,  have  shown 
how  complete  is  the  local  cure  ;  careful  microscopical  ex- 
amination of  the  peritoneal  nodules  from  these  cases  has 
shown  that  they  have  become  more  or  less  completely  con- 
verted into  fibrous  tissue,  so  that  there  is  reason  to  suppose 
that  the  cure  is  brought  about  by  a  process  of  phago- 
cytosis, or  by  some  other  method  leading  to  complete  de- 
struction of  the  tubercle-bacillus.  The  French  surgeons 
have  recently  vaunted  the  successful  results  obtained 
by  introducing  camphorated  naphtlml  (p.  8)  into  the 
peritoneal  cavity  in  cases  of  the  dry  and  of  the  ascitic  form 
of  tuberculous  peritonitis.     The  fluid  is  drawn  off  with  a 


o 


82      THE    SURGICAL    DISEASES    OF    CHILDREN 


trocar  and  canula,  and  two  to  four  drachms  of  camphor- 
ated naphthol,  are  then  introduced.  The  canula  is  with- 
drawn, and  a  collodion  dressing  is  applied  to  the  abdomen 
at  its  point  of  entrance. 

The  following  case  of  peritonitis  with  effusion  was  cer- 
tainly of  infective  origin,  and  I  believe  was  due  to  tubercle. 
It  well  illustrates  the  value  of  laparotomy  in  these  cases. 
P.  B.,  aged  14  years,  was  admitted  into  the  Victoria  Hos- 
pital for  Children.  He  had  been  wasting  for  a  month,  and 
for  the  fortnight  preceding  his  admission  he  had  com- 
plained of  a  cough  and  of  night  sweats.  His  abdomen  had 
been  swelling  for  a  week,  and  he  had  vomited  twice.  I 
found  him  to  be  an  ansemic,  emaciated  lad,  with  a  uniformly 
distended  belly,  the  skin  being  stretched  and  shiny.  The 
navel  was  flattened,  and  for  an  inch  round  it  there  was 
a  bright  red  blush,  as  though  an  abscess  were  pointing. 
There  was  a  similar  patch  of  redness  midway  between  the 
umbilicus  and  the  ensiform  cartilage  ;  this  patch  felt  oede- 
matous,  and  appeared  to  communicate  with  the  lower  one. 
The  abdominal  walls  were  so  rigid  that  nothing  could  be 
felt  through  them.  The  flanks  were  resonant,  but  a  dis- 
tinct thrill  could  be  transmitted  from  one  side  of  the 
abdomen  to  the  other.  The  lungs  appeared  to  be  healthy, 
and  the  urine  was  free  from  albumin.  The  temperature 
was  105°  F.,  the  pulse  being  120.  On  the  day  after  his 
admission  I  made  an  incision  in  the  middle  line  of  the 
abdomen,  half-way  between  the  umbilicus  and  the  ensiform 
cartilage.  Two  pints  of  a  dark  yellowish-red  fluid  escaped 
from  the  peritoneal  cavity.  The  fluid  coagulated  spon- 
taneously into  a  thick  and  jelly-like  mass  within  five 
minutes  after  its  removal.  The  wound  was  closed,  and 
was  dressed  with  cyanide  gauze. 

The  patient  bore  the  operation  well,  and  his  temperature 
began  to  fall  steadily  and  continuously,  until  it  became 


SURGICAL    AFFECTIONS    OF    THE    ABDOMEN      3S3 

normal.  Fourteen  days  later  he  was  sent  to  the  convales- 
cent home  at  Broadstairs ;  and  whilst  he  was  there,  he 
complained  of  a  pain  in  his  right  side  and  of  troublesome 
cough.  On  the  following  day  neither  breath  sounds  nor 
vocal  resonance  could  be  detected  upon  one  side,  and  the 
chest  was  absolutely  dull.  Paracentesis  was  therefore 
performed,  and  two  pints  of  clear  fluid  containing  some 
flakes  of  lymph  were  withdrawn.  The  operation  was  re- 
peated nine  days  later,  and  a  pint  of  effusion  was  removed. 
It  had  to  be  repeated  for  the  third  time  ten  days  after- 
wards, when  the  fluid  was  found  to  be  slightly  greenish  in 
colour,  but  not  at  all  purulent. 

A  year  later  the  boy  was  working  in  an  office  from  9  to 
4  daily,  and  appeared  to  be  in  excellent  health. 

The  case  is  of  interest  in  many  respects.  In  the  first 
place  all  the  external  appearances  were  misleading,  for 
they  pointed  to  a  purulent  effusion  into  the  peritoneal 
cavity,  when  in  reality  the  fluid  was  of  an  acute  plastic 
type.  The  spontaneous  coagulation  of  the  fluid  shortly 
after  its  removal  from  the  body  was  in  accord  with  all 
that  we  know  of  the  behaviour  of  the  secretions  of  acutely 
inflamed  serous  membranes.  The  withdrawal  of  a  fluid 
with  so  great  a  tendency  to  clot  must  necessarily  have 
been  productive  of  benefit  to  the  patient  by  freeing  him 
from  much  of  the  material  likely  to  produce  bands  of  adhe- 
sion with  their  attendant  evil  effects,  and  to  this  I  attribute 
in  great  measure  his  perfect  recovery,  and  the  absence  of 
any  subsequent  abdominal  symptoms. 

PERITONITIS  ASSOCIATED   WITH 
PNEUMOCOCCAL42 

Tuberculous  peritonitis  is  likely  to  be  mistaken  for 
another  insidious  form  of  peritoneal  inflammation  associ- 
ated with  the  presence  of  pneumococci. 


3^4      THE    SURGICAL    DISEASES    OF    CHILDREN 

iEtiology.— This  form  of  suppurative  peritonitis  occurs 
primarily,  when  it  may  co-exist  with  meningitis,  pleurisy, 
or  pericarditis,  or  secondarily  in  connection  with  pneu- 
monia. 

Symptoms. — It  runs  a  prolonged  course,  and  is  cha- 
racterised by  great  pain,  much  meteorism,  and  constant 
vomiting.  The  bowels  may  remain  regular  throughout 
the  attack,  and  there  is  often  a  normal  temperature. 

Diagnosis.  —  If  the  belly  be  punctured  with  an  aspi- 
rating needle,  a  greenish  pus  of  the  consistency  of  cream, 
and  having  a  tendency  to  clot,  will  be  drawn  off.  This 
pus  has  a  faint  and  characteristic  smell. 

Treatment.— The  only  treatment  which  affords  any 
prospect  of  success  in  these  cases  is  an  early  laparotomy, 
and  it  will  then  be  found  that  the  suppuration  is  either 
circumscribed  or  diffuse.  The  plastic  character  of  the 
exudation  renders  the  operation  a  difficult  one,  as  the  in- 
testines are  matted  together  by  adhesions,  if  the  operation 
has  been  delayed  for  any  length  of  time.  The  surgeon 
must  be  especially  careful  not  to  overlook  any  other  foci 
of  inflammation,  for  we  suppose  that  it  is  as  useless  to 
open  the  abdomen  in  these  cases,  when  there  is  a  similar 
condition  of  inflammation  in  the  pleura  and  pericardium, 
as  it  is  in  tuberculous  peritonitis,  when  it  forms  a  part  of 
a  general  tuberculosis. 

Peritonitis  in  the  New-born.43 

Peritonitis  in  the  new-born  usually  depends  upon 
puerperal  infection,  and  is  brought  about  by  the  direct 
extension  of  septic  inflammatory  processes  from  the 
umbilical  cord.  It  is  due  in  a  few  rare  cases  to  rupture 
of  the  bowel  resulting  from  an  imperforate  anus,  or  still 
more  rarely,  to  rupture  of  the  sigmoid  flexure,  which  has 


SURGICAL  AFFECTIONS  OF  THE  ABDOMEN   385 

been  assumed  by  Zillner  and  Genersicli  to  be  due  to  direct 
pressure  upon  the  bowel  during  parturition. 

INFLAMMATION  OF  THE  VERMIFORM  APPENDIX 
AND  APPENDICULAR  PERITONITIS. 

Inflammation  of  the  vermiform  appendix  occurs  in  males, 
in  80  per  cent,  of  the  cases,  and  in  48  per  cent,  of  these 
it  is  met  with  between  the  ages  of  15  and  30  years.  Dr. 
Deaver  stated  that  15  per  cent,  of  the  cases  occur  in 
children  under  the  age  of  puberty.  Tordeus  records  a 
fatal  case  of  perforation  of  the  vermiform  appendix 
occurring  in  a  child  of  six  months,  and  Balzer  met  with 
a  similar  case  in  a  child  aired  seven  months. 

O 

Pathology.  —  There  can  be  little  doubt  that  many 
cases  of  suppurative  inflammation  of  the  vermiform 
appendix  are  associated  with  the  presence  of  specific 
micro-organisms.  Ekehorn  has  shown  that  some  of  the 
numerous  varieties  of  the  bacillus  coli  hold  a  foremost 
position  in  this  respect,  whilst  Barbacci  of  Florence 
maintains  that  more  slowly  growing  and  less  conspicuous 
forms  of  microbe  may  also  cause  perforative  inflammation. 
The  acuteness  of  the  inflammation  appears  to  vary  with 
the  virulence  of  the  particular  culture  producing  it.  The 
micro-organisms  in  each  case  seem  to  act  bv  gaining 
access  to  the  lymphoid  tissue  in  the  submucous  coat  of 
the  appendix  through  a  lesion  in  the  lining  epithelium. 

The  simpler  forms  of  inflammation  are,  perhaps,  more 
mechanical  in  origin.  The}'  may  be  caused  by  disturb- 
ances in  the  vascular  arrangements  of  the  appendix,  due 
in  part  to  an  irregular  shape  of  the  organ  leading  to  the 
formation  of  curves  or  angles  in  its  lumen,  which  in 
turn  facilitate  the  retention  of  faecal  masses.  The  per- 
forative, as  wdl  as  the  non-perforative  forms,  are  some- 

c  u 


3S6      THE    SURGICAL    DISEASES    OF    CHILDREN 

times  associated  with  the  presence  of  foreign  bodies,  hut 
this  is  a  much  less  frequent  cause  than  has  hitherto  been 
supposed. 

etiology. — The  causes  formerly  assigned  to  inflamma- 
tion of  the  vermiform  appendix  must  now  be  considered 
as  predisposing  conditions  or  as  after-effects.  They  were 
tuberculous  and  typhoid  ulceration,  foreign  bodies,  and 
scybalous  masses.  The  scybala  so  often  found  in  inflamed 
vermiform  appendices  are  doubtless  produced  by  the 
glueing  together  of  the  faeces  by  the  increased  secretion 
from  the  mucous  glands  of  the  appendix,  the  increased 
secretion  being  one  of  the  earlier  results  of  the  inflamma- 
tion. 

Varieties,  and  Morbid  Anatomy. — Inflammation  of 
the  vermiform  appendix  is  either  simple,  perforative,  or 
relapsing,  and  each  form  may  run  an  acute,  sub-acute,  or 
chronic  course.  The  appendix  varies  greatly  in  shape, 
length,  and  position.  In  its  simplest  form  it  is  a  narrow 
tube  of  uniform  calibre,  lying  in  the  long  axis  of  the 
colon.  Its  direction,  however,  is  most  frequently  inwards  ; 
it  may  lie  behind  the  csecum,  or  it  may  even  be  situated 
in  the  true  pelvis.  The  existence  of  too  short  a  mesentery 
often  leads  to  its  puckering. 

The  inflammatory  changes  may  commence  in  the  mucous 
membrane  and  may  rapidly  involve  the  whole  organ,  or 
the  entire  thickness  of  the  walls  may  be  involved  from  the 
first,  and  in  either  case  gangrene  may  result.  The  more 
severe  forms  of  inflammation  necessarily  involve  the  sur- 
rounding tissues,  and  the  anatomical  arrangement  of  the 
peritoneum  determines  in  each  individual  whether  it 
terminates  in  a  general  peritonitis,  in  a  local  peritonitis, 
or  in  an  abscess  behind  the  peritoneum.  Dr.  Fowler  of 
Brooklyn,  to  whom  we  owe  so  much  of  our  knowledge  of 
this  form  of  disease,  has  noticed  an  abscess  of  the  anterior 


SURGICAL    AFFECTIONS    OF    THE    ABDOMEN       387 

abdominal  wall  pointing  at  the  umbilicus,  in  two  cases 
of  inflammation  of  the  vermiform  appendix  occurring  in 
children. 

Symptoms. — The  symptoms  of  acute  appendicitis  are 
so  urgent  that  they  rarely  escape  notice.  The  onset  is 
sudden,  and  in  a  typical  case  is  marked  by  very  acute 
pain,  which  after  a  short  time  is  attended  by  nausea  and 
vomiting.  The  vomiting  ceases  as  soon  as  the  stomach  has 
emptied  itself,  but  it  reappears  in  the  later  stages  of  the 
disease  when  perforation  has  occurred,  if  an  abscess  has 
been  formed,  or  if  there  is  much  intestinal  paresis.  The 
pain  after  a  time  is  paroxysmal,  and  is  in  a  t}^pical  case 
localised  to  "  McBurney's  point,"  situated  in  a  line  drawn 
from  the  anterior  superior  spine  of  the  ilium  to  the  um- 
bilicus, and  an  inch  or  an  inch  and  a  half  away  from  the 
spine  at  the  outer  border  of  the  rectus  abdominis  muscle. 
The  pain  soon  becomes  diffuse,  radiating  from  the  umbilicus 
and  into  the  pelvis.  Young  children  complain  of  "  belly- 
ache "  and  lie  curled  up  on  one  side,  though  adults  nearly 
always  assume  a  dorsal  decubitus.  In  a  few  cases  the  pain 
is  referred  to  the  right  testis  or  to  the  neck  of  the  bladder 
because  the  appendix  is  sometimes  iu  close  relation  with 
the  right  ureter,  a  point  which  should  be  carefully  borne 
in  mind  whilst  operating. 

Constipation  is  usually  a  marked  feature  in  the  attack, 
and  Dr.  Kyerson  Fowler  believes  that  it  has  some  value 
in  prognosis,  for  when  it  occurs  early  it  indicates  intestinal 
paresis  and  indicates  a  more  than  usually  severe  case. 

Too  much  reliance  must  not  be  placed  upon  the  pulse, 
respiration,  or  thermometer  in  these  cases,  for  the  worst, 
forms  may  run  their  course  without  any  great  rise  of 
temperature,  and  without  much  alteration  in  the  pulse 
rate. 

Increase  1  abdominal   pain,  with  distension  of   the   ab- 


38S      THE    SURGICAL    DISEASES    OF    CHILDREN 

dominal  walls  and  progressive  prostration,  marked  at  first 
by  a  rise  which  is  soon  followed  by  a  fall  in  tempera- 
ture, and  by  a  quicker  and  weaker  pulse,  is  characterised 
by  the  occurrence  of  diffuse  septic  peritonitis.  Collapse, 
however,  soon  sets  in,  the  vomiting  subsides,  and  the 
patient  dies. 

Diagnosis. — The  condition  is  likely  to  be  mistaken  for 
acute  intestinal  obstruction,  for  intussusception,  and,  in  the 
less  acute  forms,  for  hip  disease.  The  pain  may  lead  to  a 
diagnosis  of  biliary  or  renal  colic.  The  diagnosis  may  be 
assisted  in  the  earlier  stages  by  finding  that  the  abdominal 
muscles  are  somewhat  more  tense  upon  the  right  side,  and 
by  the  increased  tenderness  upon  this  side,  elicited  by 
rectal  examination,  as  well  as  by  the  increased  frequency 
of  micturition.  Rectal  examination  in  children  sometimes 
enables  the  surgeon  to  feel  the  outline  of  the  inflamed 
appendix.  The  temperature  in  inflammation  of  the 
appendix  rarely  rises  above  102°  F.  There  is  much 
thirst,  and  vomiting  soon  follows  the  pain,  but  it  does  not 
become  faecal  until  the  approach  of  the  fatal  termination. 
There  is  often  a  free  evacuation  of  the  bowels  at  the  be- 
ginning and  at  the  end  of  the  attack,  though  constipation 
is  the  rule  whilst  the  inflammation  is  at  its  height,  and 
tympanitis  occurs  in  the  later  stages.  There  is  also  an 
absence  of  the  mucous  discharge  which  characterises  acute 
intussusception. 

The  surgeon  is  rarely  called  upon  to  treat  a  simple  case 
of  inflammation  of  the  vermiform  appendix  ;  but  the  acute 
initial  symptoms  may  be  followed  so  quickly  by  the 
ordinary  signs  of  a  diffuse  infective  peritonitis,  that  it  is 
necessary  for  him  to  be  well  acquainted  with  the  disease 
in  all  its  forms.  The  signs  of  perforation  often  manifest 
themselves  after  the  first  defecation,  whether  it  be  spon- 
taneous or  produced  by  an  enema.     Some  surgeons  believe 


SURGICAL  AFFECTIONS  OF  THE  ABDOMEN   389 

that  the  acute  pain  in  these  cases  marks  the  instant  of 
perforation  ;  but  I  think  that  this  is  unlikely.  General 
peritonitis  often  seems  to  be  delayed,  or  it  may  never 
occur,  because  the  adhesions  prevent  the  local  inflamma- 
tion becoming  general.  A  perityphlic  or  perinephric 
abscess  is  sometimes  formed  instead  of  a  peritonitis,  and 
the  pus  may  then  track  up  the  back  for  a  considerable 
distance.  It  must  be  let  out  through  a  free  opening  in  the 
loin,  and  the  abscess  should  be  thoroughly  washed  and 
drained. 

The  inflammation  in  the  appendix  is  sometimes  re- 
current, the  patient  appearing  quite  well  in  the  intervals  ; 
but  the  frequency  of  the  attacks,  coupled  with  the  anxiety 
incident  upon  them,  may  render  him  a  chronic  invalid. 

Prognosis.— The  prognosis  in  cases  of  simple  inflam- 
mation of  the  appendix  is  good,  for  the  vast  majority  of 
cases  recover  under  medicinal  treatment.  The  prognosis 
of  perforative  inflammation,  when  the  general  peritoneal 
cavity  has  become  involved,  is  death  speedy  and  painful 
unless  laparotomy  be  performed. 

Treatment.  (1)  Therapeutic— The  duration  of  the 
uncomplicated  form  is  about  a  week,  and  it  yields  readily 
to  opium,  though,  if  one  could  be  certain  that  the  attack 
was  due  to  the  action  of  micro-organisms,  causal  treat- 
ment would  he  adopted.  Such  saline  purgatives  as 
Rochelle  salts,  administered  with  discrimination,  or  small 
d<>ses  of  calomel  with  extract  of  belladonna  or  spirits  of 
chloroform,  are  preferred  by  many  surgeons  to  opium  for 
tin;  relief  of  paill  in  such  cases,  the  object  of  the  pur-v. 
bein.u  to  wash  the  micro-organisms  out  of  the  intestine. 
Mr.  Treves  has  recently  suggested  that  salo]  as  a  powder, 
and  in  ten-grain  doses  for  an  adult,  should  be  employed  as 
an  intestinal  antiseptic.  Such  means,  however,  must  be 
used  with  the  greatesl  care,  and  are  only  to  be  recom- 


390      THE    SURGICAL    DISEASES    OF    CHILDREN 

mended  to  those  who  have  had  great  experience  in  the 
treatment  of  appendicular  peritonitis. 

Glycerine  of  belladonna — a  drachm  to  the  ounce— may- 
be used  as  an  external  application  to  relieve  the  ab- 
dominal pain,  in  addition  to  the  ordinary  hot  fomenta- 
tions which  are  so  soothing.  The  question  of  diet  is  also 
of  great  importance  in  the  treatment  of  appendicular  peri- 
tonitis. Only  such  foods  should  be  administered  as  are 
digested  by,  and  can  be  absorbed  in,  the  upper  part  of  the 
alimentary  canal.  Eggs,  peptonised  milk,  and  Benger's 
food  are  therefore  the  most  suitable  forms  of  nourishment. 

(2)  Operative. — The  question  of  operative  interference 
in  cases  of  inflammation  of  the  appendix  has  been  keenly 
debated  by  surgeons.  All  are  agreed  that  instant  opera- 
tion is  demanded  when  there  is  evidence  of  perforation, 
whether  the  accompanying  peritonitis  be  general  or  local, 
the  relapsing  cases  alone  being  open  to  discussion.  Many 
surgeons  hold  that  in  these  cases  no  operative  inter- 
ference is  admissible ;  others,  with  a  greater  show  of 
reason,  maintain  that  each  case  must  be  decided  upon 
its  own  merits,  that  when  two  or  three  relapses  have 
taken  place,  when  there  is  much  discomfort  in  the  in- 
tervals, and  when  the  patient  is  unable  to  perforin  the 
daily  duties  of  his  life,  an  operation  is  not  only  permis- 
sible, but  is  actually  indicated.  The  operation  in  such 
cases  must  be  performed  in  the  intervals  between  the 
acute  attacks,  for  the  patient  is  then  in  the  most  favour- 
able position  for  recovery,  as  no  drainage  of  the  wound 
is  required,  and  union  by  first  intention  may  be  antici- 
pated with  confidence.  Recurrent  peritonitis  must  be 
distinguished  from  chronic  relapsing  peritonitis.  The  re- 
current forms  appear  to  be  due  to  mechanical  causes 
brought  into  play  by  digestive  disturbances,  whilst  the 
chronic  relapsing  condition  is  due  to  the  presence  of  some 


SURGICAL    AFFECTIONS    OF    THE    ABDOMEN 


\9l 


local  infective  lesion.  The  recurrent  form  should  be  left 
alone  ;  the  chronic  relapsing  type  demands  operation  when 
the  interval  between  the  attacks  is  short,  and  there  is 
evidence  of  the  persistence  of  suppuration. 

When  the  abdomen  does  not  contain  purulent  fluid,  the 
patient  may  be  placed  in  the  position  recommended  by 
Trendelenburg  (fig.  41),  with  the  abdomen  on  a  slightly 
higher    level    than   the  head    and    the    feet,  as    it    facili- 


p[f5_  4i. Fowler"*   modification  of    Trendelenburg's  Operating  Table,  for 

use  in  abdominal  explorations.  It  is  capable  of  lateral  rotation.  The  angle 
at  which  the  table  is  set  in  the  drawing  is  much  too  acute. 

[Copied  /.»>;  permission  from  the  "Annals  of  Surgery,"  vol.  xix.,  1891.] 

t :i tes  an  examination  of  the  abdominal  cavity.  Dr. 
McBurney  then  makes  an  oblique  incision  in  the  skin, 
about  4  inches  long  in  an  adult,  and  nearly  at  right 
angles  to  a  line  drawn  from  the  anterior  superior  spine 
of  the  ilium  to  the  umbilicus.  The  incision  is  carried 
about  1  inch  from  the  iliac  spine,  and  is  so  situated  that 
its  upper  third  lies  above  a  line  carried  from  the 
anterior  superior  spine  of  the  ilium  to  the  umbilicus, 
whilst    it   terminates   just    opposite    the   deep   epigastric 


39^      THE    SURGICAL  'DISEASES    OF    CHILDREN 

artery.  The  aponeurosis  of  the  external  oblique  is  next 
divided,  and  then  the  internal  oblique  and  the  trans- 
versalis,  but  not  to  the  full  extent  of  the  skin  incision, 
and  more  towards  the  inner  than  the  outer  portion.  The 
fibres  of  the  muscles  and  aponeurosis  are  separated,  and 
are  not  cut  across,  as  there  is  then  less  tendency  to  the 
formation  of  a  hernia. 

An  incision  is  made  through  the  least  tympanitic  part, 
if  an  abscess  can  be  localised,  though  in  cases  of  diffuse 
peritonitis  the  position  of  the  swelling  must  determine  the 
line  of  the  incision ;  for  if  it  projects  into  the  loin,  the 
abdomen  must  be  opened  parallel  with  Poupart's  ligament, 
whilst  if  the  swelling  is  well  to  the  inner  side  of  the 
anterior  superior  spine  of  the  ilium,  the  incision  must  be 
carried  immediately  to  the  inner  side  of  the  linea  semi- 
lunaris, so  as  to  divide  the  rectus  muscle  rather  than  the 
fascia,  for  the  muscle  heals  better,  and  there  is  less  chance 
of  a  ventral  hernia  than  when  the  linea  semilunaris  itself 
is  cut  through. 

Great  care  must  be  taken  as  soon  as  the  peritoneum  is 
reached,  lest  the  appendix  or  csecum  should  be  inadver- 
tently injured.  The  general  peritoneal  cavity  must  be 
cut  off  at  once  from  the  area  of  the  operation,  if  the 
peritonitis  is  found  to  be  localised.  This  is  best  done 
by  protecting  the  parts  with  gauze,  which  has  been 
sterilised  without  the  addition  of  any  antiseptic  agent. 
The  vermiform  appendix  is  exposed  and  carefully  ex- 
amined ;  if  it  is  distended,  discoloured,  and  unruptured, 
it  may  be  removed  by  clamping  it  close  to  the  caecum, 
passing  an  aseptic  silk  ligature  round  it  about  half  an 
inch  away  from  the  gut,  and  cutting  off  the  appendix 
below  the  ligature.  A  cuff-shaped  flap  may  be  made  in 
exceptionally  favourable  cases,  or  when  the  operation 
is  performed   for   relapsing    inflammation,  in  the  manner 


SURGICAL  AFFECTIONS  OF  THE  ABDOMEN   393 

described  by  Dr.  Fowler  (Annals  of  Surgery,  xix.,  1894, 
p.  348),  the  mucous  membrane  exposed  iu  the  wound  being 
destroyed  by  a  single  application  of  fuming  nitric  acid. 

A  similar  method  of  treatment  may  be  adopted  when 
a  localised  abscess  of  some  days  or  weeks'  duration  has 
ruptured,  and  if  the  general  peritoneal  cavity  has  become 
involved  in  the  inflammatory  process.  The  abdomen 
should  be  then  thoroughly  flushed  with  a  2  per  cent, 
s  lution  of  peroxide  of  hydrogen.  The  abscess  must  be 
opened  and  drained  when  adhesions  have  been  formed 
between  the  vermiform  appendix  and  the  abdominal  wall  : 
but  care  should  be  taken  not  to  break  down  the  adhesions 
separating  the  abscess  from  the  peritoneal  cavity.  The 
appendix  in  such  cases  should  neither  be  looked  for  nor 
removed.  The  abscess  should  be  emptied  if  symptoms  of 
obstruction  be  present,  its  cavity  should  be  disinfected  ;  and 
if  the  obstructing  adhesions  can  be  identified,  they,  and 
they  only,  should  be  divided  ;  but  if  they  cannot  be  iden- 
tified, all  the  adhesions  must  be  separated,  and  the  vermi- 
form appendix  must  be  removed. 

The  surgeon  must  decide  for  himself  in  each  case  what 
must  be  done  to  the  peritoneal  cavity.  Thorough  but 
gentle  sponging  is  sufficient  when  the  peritonitis  is  local ; 
but  if  it  be  general,  it  should  be  well  fffished  with  a  (Hi 
per  cent,  solution  of  common  salt  at  the  temperature  of  the 
body.  The  abdominal  wound  is  eventually  sewn  up,  after 
a  double  drainage-tube  has  been  inserted.  When  from 
any  cause  the  vermiform  appendix  cannot  be  found,  or  it  is 
deemed  inexpedient  to  break  down  local  adhesions,  lest  the 
inflammation  should  become  generalised,  it  is  usual  to 
drain  the  wound  by  introducing  into  its  depths  a  strip  or 
two  of  sterile  gauze,  which  must  be  renewed  at  each 
dressing. 

After-Treatment.— The    after-treatment    consists    in 


394      THE    SURGICAL    DISEASES    OF    CHILDREN 

feeding  with  nutrient  enemata  or  peptonised  milk  for 
three  days,  and  then  gradually  increasing  the  amount  and 
solidity  of  the  food;  when  the  bowels  require  to  be  opened, 
one-tenth  of  a  grain  of  calomel  may  be  given  every  hour 
until  defecation  takes  place. 

INTUSSUSCEPTION.44 

etiology. — Intussusception  occurs  in  children  at  all 
ages,  though  it  is  perhaps  a  little  more  frequent  during 
the  teething  period  than  at  other  times.  It  runs  either  an 
acute  or  a  chronic  course.  The  predisposing  as  well  as  the 
exciting  causes  are  quite  unknown,  but  it  is  supposed  that 
peripheral  as  well  as  local  irritation  may  produce  it. 

Morbid  Anatomy.— Leichtenstern  classifies  the  various 
forms  of  intussusception  as  follows  :  the  ileum  into  the 
ileum,  or  ileo-ileac  invagination ;  the  colon  into  the  colon, 
or  colon  invagination  ;  the  ileum  at  the  ileo-csecal  valve,  and 
involving  it  or  the  colon — ileo-csecal  invagination.  Lastly, 
the  ileum  into  the  colon  without  infolding  of  the  ileo-csecal 
valve,  or  the  ileo-colic  invagination.  The  invagination  is 
nearly  always  descending ;  but  a  few  years  since  I  brought 
under  the  notice  of  the  Pathological  Society  an  instance  of 
the  true  ascending  variety  which  had  occurred  during  life, 
for  the  intussuscipiens  was  united  to  the  intussusceptum 
by  a  plastic  deposit. 

Symptoms. — An  acute  intussusception  may  occur  in  a 
child  who  is  apparently  in  good  health.  There  is  a  sudden 
attack  of  abdominal  pain,  with  repeated  vomiting,  and  the 
passage  of  small  quantities  of  blood  and  mucus  by  the 
rectum.  The  pain  is  often  very  violent ;  it  is  usually  con- 
tinuous, but  is  liable  to  paroxysmal  increase.  It  is  accom- 
panied by  much  straining,  with  screaming  and  kicking. 
After  a  short  time  there  is  usually  complete  constipation, 


SURGICAL  AFFECTIONS  OF  THE  ABDOMEN   395 

though  in  a  few  cases  this  is  replaced  by  diarrhoea.  The 
most  characteristic  sign  of  the  disease  is  the  formation  of 
a  definite  tumour,  which  can  be  felt  through  the  walls  of 
the  abdomen,  and  in  some  cases  by  a  finger  introduced  into 
the  rectum.  The  tumour  is  smooth,  slightly  movable,  not 
very  tender,  and  cylindrical.  It  is  felt  in  a  typical  case 
above  the  umbilicus,  and  shades  away  towards  the  right 
flank,  extending  along  the  right  linea  semilunaris.  The 
presence  of  the  tumour  may  be  masked  by  tympanites. 
Rectal  examination,  when  the  tumour  has  advanced  into 
the  left  flank,  as  it  soon  does,  will  sometimes  reveal  it  as  a 
congested  mass  with  a  central  aperture  somewhat  resem- 
bling the  adult  os  uteri.  This  mass  may  be  seen  and  felt 
to  advance  when  the  child  strains. 

Prognosis. — Recovery  may  take  place  spontaneously 
in  slight  cases,  or  by  sloughing  and  adhesion  of  the  two 
parts  of  the  intestine  in  the  more  advanced  forms.  This 
termination  is  so  rare,  however,  that  expectant  treatment 
must  never  be  adopted,  or  even  suggested  in  acute  cases. 
Death  from  exhaustion  or  peritonitis  usually  takes  place 
between  the  fourth  and  seventh  days  in  cases  of  untreated 
intussusception,  and  the  pain  is  so  atrocious  until  gangrene 
of  the  intestine  occurs,  that  no  child  should  be  left  to  die 
in  this  manner.  In  some  cases,  however,  it  runs  a  very 
slow  course. 

Diagnosis.— Intussusception  has  to  be  diagnosed  from 
the  other  forms  of  acute  intestinal  obstruction  which  are 
common  in  children.  No  mistake  is  likely  to  be  made  if  the 
cylindrical  tumour  can  be  felt  in  the  left  flank  ;  but  if  it  be 
not  present,  the  differential  diagnosis  between  intussus- 
ception, some  forms  of  suppurative  peritonitis,  inflamma- 
tion of  the  appendix,  and  the  obstruction  due  to  pressure 
from  enlarged  mesenteric  glands,  may  be  very  difficult, 
and  can  only  be  made  by  performing  an  abdominal  section. 


<•> 


96      THE    SURGICAL    DISEASES    OF    CHILDREN 


A  marked  depression  in  the  right  iliac  fossa  (Signe  de 
Danz),  from  the  displacement  of  the  colon  to  the  left  side, 
may  give  a  cine  to  the  diagnosis  of  intussusception.  Col- 
lapse usually  occurs  earlier,  and  is  a  more  marked  symptom 
in  intussusception  than  in  other  forms  of  acute  intestinal 
obstruction  in  children. 

Treatment. — The  treatment  is  exactly  similar  to  that 
adopted  for  a  strangulated  hernia  ;  inflation  of  the  bowel 
and  kneading  the  abdomen  taking  the  place  of  taxis,  whilst 
laparotomy  replaces  herniotomy.  Intussusception,  indeed, 
may  be  considered  as  occupying  that  place  in  the  surgery 
of  children  which  is  filled  by  strangulated  hernia  in 
adults ;  for  just  as  intussusception  is  common  in  children 
whilst  strangulated  hernia  is  rare,  so  in  adults  strangulated 
hernia  is  common  and  intussusception  is  rare.  The  same 
arguments  for  treatment  by  operative  measures  apply  in 
both  cases.  As  in  hernia  no  one  would  think  of  operating 
before  he  had  applied  taxis,  so  in  intussusception  no  one 
would  perform  laparotomy  before  he  had  tried  inflation  of 
the  bowel.  Prejudice  dies  hard  ;  and  as  even  to  the  time 
of  Percivall  Pott  there  were  many  surgeons  who  held  that 
the  medical  treatment  of  hernia  was  alone  legitimate,  so 
in  our  own  time  there  are  some  who  have  doubts  as  to  the 
advisability  of  opening  the  abdomen  in  cases  of  intus- 
susception ;  yet  in  children  laparotomy  is  not  a  more 
dangerous  operation  than  is  herniotomy  in  adults. 

The  success  of  the  treatment  depends,  both  in  hernia 
and  in  intussusception,  upon  the  case  being  seen  in  the 
earliest  possible  stage ;  but  in  both  diseases  the  processes 
may  be  so  acute,  and  may  have  run  so  peculiar  a  course,  as 
to  render  death  inevitable.  At  St.  Bartholomew's  Hospital, 
in  1893,  the  abdomen  was  opened  seven  times  for  intussus- 
ception :  in  five  cases  the  intussusception  was  reduced  ;  all 
these  cases  recovered.     Three  of  the  patients  were  under 


SURGICAL    AFFECTIONS    OF    THE    ABDOMEN      $97 

one  year  of  age.  Two  infants,  aged  six  months  and  seven 
months,  died  after  laparotomy  and  incision  of  the  intussus- 
ception. 

Inflation  of  the  intestine  should  be  tried  directly  the 
surgeon  has  diagnosed  the  presence  of  an  intussusception, 
but  arrangements  should  he  made  for  proceeding  at  once  to 
a  laparotomy  in  case  it  fails.  The  child  should  be  clothed 
in  a  jacket  of  absorbent  wool,  roughly  tacked  together  for 
the  occasion,  and  its  legs  and  thighs  should  be  protected 
by  wool  and  bandages,  for  it  is  of  great  importance  to  keep 
him  warm  during  the  necessary  manipulations.  He  is  then 
placed  upon  a  small  water-bed,  half-filled  with  water  at  a 
t  niperature  of  lKP  F.,  over  which  is  placed  a  single  fold 
of  blanket  and  a  mackintosh  sheet.  He  is  ansesthetised, 
and  an  oiled  and  warmed  catheter  is  gently  introduced  into 
the  rectum,  an  assistant  compressing  the  buttocks  to  keep 
the  anus  closed  round  it.  The  end  of  the  catheter  is  con- 
nected with  four  feet  of  india-rubber  tubing  terminating 
in  a  funnel.  The  tubing,  with  a  qiiart  jug  of  OG  per  cent. 
salt  solution  at  a  temperature  of  100°  P.,  is  given  into  the 
charge  of  the  second  assistant.  The  child  is  then  inverted 
and  held  by  a  nurse,  whilst  the  assistant  is  directed  to  till 
the  tube  with  salt  solution,  and  to  raise  the  funnel  from  2| 
to  3  feet  above  the  child's  anus.  If  fluid  enters  the  bowel, 
;il) out  a  pint  may  be  introduced,  the  surgeon  at  the  same 
time  gently  kneading  the  abdomen  with  his  finger-tips  and 
the  flat  of  his  hand  in  the  course  of  the  colon  from  the 
sigmoid  flexure  towards  the  ileo-csecal  valve. 

The  success  of  the  injection  is  marked  by  the  disappear- 
ance of  the  tumour,  by  a  gurgling  beyond  it,  and  by  the 
distension  of  the  intestine  upon  its  csesal  side.  When  this 
happens,  the  child  should  be  laid  down,  the  tube  removed, 
and  in  a  shorl  time  he  should  be  put  quietly  to  bed,  with 
as  little  movement   as  possible.     He  shoull  be  carefully 


39§      THE    SURGICAL    DISEASES    OF    CHILDREN 

watched,  however,  for  it  often  happens  that  the  intussus- 
ception recurs,  and  the  operation  of  inflation  may  have  to 
be  repeated. 

Many  other  means  of  inflation  have  been  employed — air, 
water,  oil,  milk,  and  hydrogen  being  the  most  usual.  Some 
surgeons  prefer  to  inflate  with  a  Higginson's  syringe.  The 
operation  is  always  attended  by  some  danger  of  rupturing 
the  bowel,  and  it  must  therefore  be  performed  with  the 
greatest  gentleness.  Eight  to  ten  ounces  of  fluid,  allowed 
to  make  its  own  way  into  the  bowel  from  a  height  of  three 
feet,  is  sufficient  for  a  child  of  nine  months  old ;  the  amount 
and  the  force  may  be  increased  with  the  age- 
Inflation  is  useless  when  the  intussusception  is  beyond 
the  caecum  in  the  small  intestine  ;  it  is  equally  useless  when 
the  intussusception  projects  beyond  the  anus,  and  Dr.  Taylor 
thinks  that  it  is  an  unsuitable  form  of  treatment  when  a 
tumour  cannot  be  felt,  and  the  diagnosis  depends  entirely 
upon  the  symptoms.  It  is,  of  course,  absolutely  useless  in 
the  latest  stages  of  the  disease,  when  adhesions  have  taken 
place,  and  when  there  is  a  suspicion  of  peritonitis.  As  a 
general  rule,  it  should  only  be  adopted  within  three  days 
from  the  onset  of  the  symptoms. 

Laparotomy  should  be  performed  as  soon  as  the  surgeon 
has  assured  himself  that  inflation  is  ineffectual ;  but  he 
should  bear  in  mind  that  the  earlier  the  operation  is  per- 
formed, the  better  results  will  he  obtain  ;  that  it  is  never  to 
be  performed  as  a  last  resource  ;  and  that  if  it  can  be  done 
within  twenty-four  hours  of  the  onset  of  the  symptoms,  the 
child  will  probably  recover.  It  is  even  more  necessary  to 
perforin  laparotomy  early  in  cases  of  intussusception  than 
it  is  to  perform  herniotomy  early  in  cases  of  strangulated 
hernia  ;  for  the  intussusception  is  more  acute,  and  the  deli- 
cate tissues  of  the  child  bear  the  inflammation  worse.  The 
incision  through  the  abdominal  Avails  is  to  be  made  so  as  to 


SURGICAL    AFFECTIONS    OF    THE    ABDOMEN       399 

expose  the  tumour,  either  in  the  middle  line,  in  the  left 
or  in  the  right  linea  semilunaris.  The  same  precautions 
for  keeping  the  patient  warm  must  be  adopted  as  during 
inflation  (p.  397).  The  intussusception  is  reduced  by  gently 
pushing  and  squeezing  the  intussuscepted  portion  of  the 
bowel  out  of  the  intussuscepting  part,  but  never  by  directly 
pulling  it  out.  It  will  generally  be  found  that  a  very 
moderate  amount  of  pressure  is  sufficient  to  effect  reduc- 
tion ;  but  care  should  be  taken  to  see  that  the  reduction  is 
complete,  and  if  necessary  the  mesentery  may  be  shortened. 
The  abdomen  is  then  closed  with  sutures  passing  through 
the  whole  thickness  of  its  wall,  including  the  peritoneum, 
and  it  is  dressed  in  the  ordinary  manner. 

Many  methods  have  been  adopted  for  the  treatment  of 
intussusceptions  which  have  proved,  after  laparotomy,  to  be 
irreducible  or  gangrenous.  These  methods  may  be  summed 
up  as  longitudinal  incision  of  the  bowel,  suture  of  the 
intussusceptum  and  intussuscipiens,  with  removal  of  the 
intussuscepted  part,  resection  and  immediate  suture,  the 
formation  of  an  artificial  anus.  No  case  of  irreducible 
intussusception  has  come  under  my  care,  and  such  cases 
will  doubtless  become  less  frequent  as  the  advantage  of 
early  operation  becomes  more  widely  known,  though  they 
will  always  occur  in  the  chronic  as  well  as  in  the  most 
acute  forms  of  the  disease.  Barker's  operation  appears 
most  likely  to  yield  satisfactory  results.  He  sutures  with 
chromic  gut  the  intussuscepted  portion  of  the  bowel  to  the 
intussuscepting  part  at  its  point  of  entrance.  He  then 
lays  the  bowel  open  by  a  longitudinal  incision,  turns  out 
the  invaginated  part  and  cuts  it  short  off,  sutures  the  in- 
cision in  the  intestine,  and  thus  restores  its  lumen. 

After-Treatment. — The  child  is  put  to  bed  and  fed  upon 
peptonised  milk  and  beef-juice  or  essence.  Opium  may  be 
given  if  there  is  evidence  of  local  peritonitis  at  the  time  of 


4-OQ      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  (Operation,  but  it  is  not  required  as  a  matter  of  routine  ; 
and  when  it  is  given,  it  is  better  to  feed  the  child  by  the 
rectum. 

Chronic  Intussusception.15 

Chronic  intussusception  runs  a  very  slow  course, 
though  it  may  begin  with  acute  or  sub-acute  symptoms. 
The  constant  pain  subsides,  but  there  are  daily  attacks  of 
paroxysmal  pain  recurring  with  more  or  less  frequency. 
Vomiting  may  be  absent,  and  there  may  be  no  obstruction 
of  the  bowels,  so  that  the  case  may  be  treated  as  one 
of  simple  enteritis,  and  the  true  nature  of  the  disease  may 
only  be  clear  when  a  portion  of  the  ileum  protrudes  at 
the  anus,  though  there  is  even  then  a  chance  that  it  may 
be  mistaken  for  a  case  of  simple  prolapse.  The  condition 
of  the  bowel  in  these  cases  appears  to  be  that  of  simple 
invagination  rather  than  of  inflammation,  strangulation, 
or  inflammatory  adhesion  of  its  layers.  The  circulation 
through  the  walls  of  the  intestine,  therefore,  remains  free, 
and  this  accounts  for  the  benignant  course  taken  by  the 
disease. 

Treatment. — The  treatment,  if  the  condition  is  recos:- 
nised  early,  consists  in  inflation ;  but  laparotomy  has 
yielded  good  results  even  a  fortnight  or  a  month  after  the 
onset  of  the  symptoms. 


CHAPTER  XIX 
HERNIA   AND   ITS   TREATMENT40 

The  subject  of  hernia  is  of  great  importance  in  children, 
partly  because  it  is  so  frequent,  and  partly  because  sur- 
geons are  now  beginning  to  recognise  that  so  much  can 
be  done  to  cure  it.  It  is  either  umbilical  or  inguinal,  but 
in  each  case  there  is  an  acquired  as  well  as  a  congenital 
form.  Strangulation  is  less  common  than  in  adults,  and  it 
happens  that  two  cases  of  strangulated  umbilical  hernia 
have  come  under  my  care  during  the  past  year.  Well- 
applied  trusses  and  careful  management  effect  a  cure  in  a 
very  large  majority  of  cases ;  but  there  is  always  a  resi- 
duum in  which  these  means  fail.  For  such  cases  opera- 
tive treatment  must  be  adopted,  for  it  is  practically 
free  from  danger,  and,  except  in  rare  cases,  is  effectual  in 
preventing  a  recurrence  of  the  rupture. 

LUMBAR   HERNIA. 

Lumbar  hernia  occasionally  occurs  in  children  as  a 
protrusion  of  gut  in  the  loin,  due  in  some  cases  to  con- 
genital defects  in  the  region  of  Petit's  triangle,  and  in 
others  to  a  weakening  of  the  abdominal  walls,  caused  by 
the  formation  of  an  abscess  connected  with  perinephric  or 
vertebral  disease.  The  hernia  is  reducible,  and  contains 
colon.  The  treatment  consists  in  the  application  of  a 
truss  in  the  congenital  forms,  or  in  suture  of  the  muscular 
walls  over  the  hernia  in  the  secondary  variety. 

401  D    n 


4-02      THE    SURGICAL    DISEASES    OF    CHILDREN 

VAGINAL   HERNIA. 

A  vaginal  hernia  sometimes  occurs  as  a  congenital  defect. 
It  projects  at  the  vulva  as  an  extension  from  the  vesico- 
vaginal pouch  of  peritoneum.  Mr.  Holmes  performed  a 
radical  cure  of  such  a  hernia  by  first  reducing  it,  and  then 
dissecting  flaps  of  mucous  membrane  from  either  side  of 
the  vagina  and  suturing  them  over  the  site  of  the  pro- 
trusion. 

UMBILICAL   HERNIA. 

Umbilical  hernia  is  either  congenital,  when  it  is  an 
exomphalos  or  omphalocele,  the  child  being  born  with 
some  of  its  intestines  still  protruding  into  its  umbilical 
cord.  It  is  sometimes  acquired,  when  it  is  merely  a  dilata- 
tion of  the  navel  to  a  greater  or  less  extent.  Exomphalos 
is  not  really  a  hernia  in  the  true  sense  of  the  term,  for  the 
ectopic  intestines  were  never  included  in  the  abdomen.  It 
is  always  a  serious  condition,  and  may  be  associated  with 
other  congenital  defects,  most  frequently,  it  is  said,  with 
spina  bifida  ;  but  I  have  never  seen  them  together. 

Signs. — The  protrusion  consists  of  a  neck  of  skin  con- 
tinued into  a  translucent  sac  composed  of  the  coverings 
of  the  umbilical  cord.  The  outlines  of  the  intestine  can 
often  be  distinctly  seen  through  the  sac,  as  is  represented 
in  fig.  42. 

Prognosis. — An  attempt  should  always  be  made  to 
reduce  an  umbilical  hernia  as  soon  as  possible,  though  this 
may  fail  owing  to  the  large  amount  of  gut  in  the  sac,  and 
the  small  size  and  very  resistant  nature  of  the  aperture 
in  the  umbilicus.  An  operation  is  absolutely  necessary  if 
the  intestine  cannot  be  reduced ;  for  if  it  is  not  performed, 
an  adhesive  and  possibly  a  suppurative  peritonitis  will 
be  set  up  by  an  extension  of  the  process  by  which  the 


HERNIA    AND    ITS    TREATMENT 


40; 


umbilical  cord  is  separated,  the  sac  may  slough,  and  the 
child  will  die  of  general  peritonitis. 

I  saw  a  good  instance  of  this  a  short  time  since,  when  a 
child,  two  days  old,  was  brought  to  me  with  a  well-marked 
exomphalos.  The  sac  was  black  and  stinking  at  the  point 
where  the  cord  had  been  tied.  The  child  had  a  subnormal 
temperature,  its  bowels  had  been  opened  three  times  since 
its  birth,  it  had  passed  urine,  and  its  belly  was  only 
slightly  swollen  and  tender.  I  laid  the  sac  freely  open, 
and  in  doing  so  found  that  its  walls  were  very  thick  and 


Fig.  12.— Congenital  umbilical  hernia— exomphalos. 
[From  the  "  Transactions  of  the  Pathological  Society  of  London."] 


03  Lematous.  It  contained  a  large  bundle  of  intestine 
matted  together  by  tough  yellow  lymph.  The  lymph  was 
carefully  peeled  away  with  the  finger  and  thumb,  and  the 
mass  was  gradually  unravelled  until  it  was  found  to  con- 
sist of  the  caecum  with  the  vermiform  appendix  and  about 
Three  inches  of  the  ileum.  The  intestine  was  congested, 
but  it  was  not  gangrenous,  and  it  was  intimately  adherent 
to  the  boundaries  of  the  umbilicus.  The  adhesions  were 
broken  down  with  a  probe,  the  intestines  were  washed 
with  very  hot  water,  and  an  attempt  was  made  to  replace 
them.     The  caecum,  however,  could  not  be  returned  until 


404      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  abdominal  wall  had  been  divided.  The  sac  was  cut 
away,  and  the  ring  and  the  abdominal  wall  were  closed 
with  silver  sutures  and  antiseptic  dressings  were  applied. 
The  child  bore  the  operation  well,  but  died  twenty-four 
hours  later.  A  number  of  this  class  of  cases  have,  how- 
ever, been  successfully  operated  upon  by  various  surgeons. 

A  piece  of  intestine  may  protrude  at  any  point  in  the 
linea  alba,  though  the  umbilicus  forms  its  most  common 
exit.  The  ordinary  cases  of  ruptured  navel  are  of  much 
less  importance  than  an  omphalocele.  They  are  some- 
times cylindrical  or  conical,  and  sometimes  rounded  or 
button-shaped.  They  give  rise  to  little  or  no  trouble, 
and  their  spontaneous  cure  is  the  rule. 

Treatment. — They  are  treated  by  removing  as  far  as 
possible  any  cause  leading  the  child  to  strain,  such  as 
cough  and  phimosis.  The  local  treatment  consists  in 
sewing  a  penny  into  a  couple  of  layers  of  lint.  The  child 
is  placed  flat  upon  its  back,  the  rupture  is  returned,  and 
the  pad  thus  made  is  applied  from  below  upwards,  so  as 
to  convert  the  umbilical  aperture  into  a  slit.  The  bowel 
is  thereby  prevented  from  extruding,  and  the  pad  is 
secured  in  place  by  two  strips  of  waterproof  strapping 
placed  crosswise  over  it.  A  broad  flannel  bandage  is 
then  sewn  round  the  abdomen,  and  the  pad  and  bandage 
are  changed  by  the  surgeon  as  often  as  may  be  necessary, 
care  being  taken  on  each  occasion  that  the  rupture  does 
not  protrude.  It  is  to  be  noted  that  those  appliances  for 
umbilical  hernia  are  highly  objectionable  which  are  made 
to  project  into  the  umbilical  ring.  They  prevent  the 
natural  process  of  closure.  A  radical  cure  may  be  neces- 
sary in  a  few  rare  cases  when,  in  spite  of  all  treatment, 
the  rupture  steadily  increases  in  size.  The  sac  should 
not  be  opened  during  its  performance,  nor  should  it  be 
removed. 


HERNIA    AND    ITS    TREATMENT 


405 


INGUINAL  HERNIA. 
Everything  connected  with  inguinal  hernia  in  child- 
hood is  of  the  greatest  interest  to  the  surgeon,  on  account 
of  the  frequency  with  which  he  is  consulted  about  the 
affection.  It  occurs  in  the  children  of  the  poor  rather 
more  often  than  in  those  of  the  well-to-do.  In  each 
class,  however,  it  presents  important  features.  Rupture 
in  a  pauper  child  precludes  a  livelihood  from  mechanical 
toil,  often  the  only  means  of  subsistence  available  to  it. 


Fig.  43.— Diagram  of  the  lower  part  of  the  abdomen  of  a  child,  aged  eight 
months.  The  external  abdominal  rinic  is  immediately  below  the  "  fold  of 
Venus."  Its  situation  on  the  left  side  is  indicated  by  a  transverse  line.  (After 
Felizet.) 

Rupture  often  renders  the  son  of  wealthy  parents  mor- 
bidly self-conscious,  prevents  him  from  making  the  best 
use  of  his  education  at  a  public  school,  and  eventually 
shuts  him  out  of  the  public  services  for  which  by  in- 
terest or  merit  ho  might  be  otherwise  peculiarly  well 
suited.  A  truss  is  often  useless  for  a  poor  child  who  has 
no  personal  attendant  to  see  that  it  is  properly  adjusted, 
that  the  skin  does  not  become  chafed,  and  that  the  pad 
is  not  worn  over  the  unreduced  rupture.  In  the  rich  a 
truss  may  become  a  source  of  danger  by  being  worn  so 
assiduously  as    to  lead   to   the    apparent   and   temporary 


406     THE    SURGICAL    DISEASES    OF    CHILDREN 

cure  of  a  hernia,  the  gut  often  reappearing  in  later  life 
and  perhaps  at  some  critical  moment. 

Predisposing  tCauses. — Abnormal  conditions  of  the 
abdominal  wall  and  defective  closure  of  the  upper  part  of 
the  tunica  vaginalis  testis  are  the  most  common  predispos- 
ing causes  of  hernia  in  children.  Fere  examined  sixty-two 
children  under  a  month  old,  and  found  that  in  only  thirty- 
four  was  the  vaginal  process  completely  closed  on  both 
sides. 

Morbid  Anatomy. — Dr.  Felizet  has  pointed  out,  as 


Fig.  44. — Diagram  of  the  lcmer  part  of  the  abdomen  of  a  child,  aped  four 
yeais.  The  external  abdominal  ring  is  situated  loner  than  in  the  preceding 
figure,  but  not  so  low  as  in  the  succeeding  one.    (After  Felizet.) 


is  seen  in  the  annexed  diagrams  (figs.  43,  44,  45), 
modified  from  his  most  valuable  work,  Inguinal  Hernia 
in  Children,  that  in  young  adults  (fig.  45)  the  external 
abdominal  ring  lies  low  in  the  abdomen,  at  least  two  or 
three  finger-breadths  below  the  crease  known  to  artists 
as  the  "  fold  of  Venus  "  ;  in  infants  of  a  few  months  old 
(fig.  43),  the  external  ring  lies  on  a  level  with  this  fold, 
whilst,  as  they  get  older  (fig.  44),  and  the  pelvis  be- 
comes better  developed,  the  position  of  the  ring  slowly 
approaches   the   point    it   occupies    in   adult    life.      The 


HERNIA    AND    ITS   TREATMENT 


407 


widening  of  the  pelvis  also  causes  the  inguinal  canal  to 
increase  in  length,  for  at  birth  it  hardly  exists.  These 
anatomical  points  are  of  great  importance  in  considering 
inguinal  hernia  in  children,  and  they  can  be  readily 
verified  by  invaginating  the  scrotum,  and  feeling  with  the 
little  finger  for  the  abdominal  ring.  It  will  then  be  found 
that  the  rings  themselves  are  proportionately  larger  in  the 
child  than  in  an  adult,  whilst  the  inguinal  canal  is  so 
short  that  the  internal  abdominal  ring  in  an  infant  is  in 
close  proximity  to  the  external  ring.     These  are  all  points 


Fig.  16. — Diagram  of  the  lower  part  of  the  abdomen  of  a  boy,  ajjed  fourteen. 
'Die  external  abdominal  rhiLj  nearly  occupies  ihe  position  which  it  does  in  the 
adult.     (After  Felizet.) 

of    normal  anatomy  in   a   child  ;    if  it  be  predisposed   to 
rupture,  certain  additional  defects  may  be  obvious. 

The,  pillars  of  the  ring  may  bo  defective,  and  this  also 
has  been  worked  out  with  much  care  by  Dr.  Felizet,  who 
finds  that  the  pillars  are  more  often  defective  in  boys  than 
in  girls.  He.  assumes  that  the  normal  (fig.  46)  pillars 
should  be  thick,  solid,  and  so  tense  that  they  vibrate  when 
thoy  are  touched  l>y  the  finger,  and  contract  the  ring 
when  the  child  cries,  si  rains,  or  makes  an  effort.  He  has 
paet  with  pillars  of  this   kind    in   '21    per   rciit.nl'  85  cases 


40S      THE    SURGICAL    DISEASES    OF    CHILDREN 


in  which  he  has  made  a  careful  examination  during  the 
performance  of  the  radical  operation  for  the  cure  of  in- 
guinal hernia.     The  aponeurosis  of  the  external  oblique 


Fig.  46. — Diagram  representing 
a  normal  external  abdominal  ring. 
Both  pillars  are  well  developed. 
(After  Felizet.) 


Fig.  47. — Diagram  representing 
a  defective  external  abdominHl 
ring  ;  the  outer  pillar  is  imperfectly 
developed.     After  Felizet.) 


lying   above   the  ring  should  be  firm,  well  defined,    not 
frayed  out,  and  provided  with  a  sufficient  number  of  inter- 


Fig.  48. — Diagram  representing  a  defective  external  abdominal  ring;  the 
inner  pillar  is  imperfectly  developed.    (After  Felizet.) 

columnar  fibres  running  transversely  across  the  canal. 
The  departures  from  this  type  of  ring  are  in  two  direc- 
tions :    the  pillars  are  either  weak  and  delicate,  with  a 


HERNIA    ANT)    ITS    TREATMENT 


409 


sharp  edge  which  is  never  taut ;  or,  one  or  other  pillar 
may  be  absent  either  completely  or  in  part.  Weak  pillars 
occurred  in  17  per  cent,  of  Dr.  Felizet's  cases,  and 
defective  pillars  in  no  less  than  Gl  per  cent,  of  his  exami- 
nations in  children  affected  with  hernia.  The  weak  pillars 
of  the  ring  do  not  close  upon  the  finger  in  the  same  active 
way  as  the  normal  ones  do  when  the  child  strains,  and 
they  are  often  associated  with  a  flabby  condition  of  the 
aponeurosis  of  the  external  oblique,  whilst  the  muscle 
itself  is  not  well  connected  with  the  rectus  of  its  own 


Fig.  49.— Diagram  representing  a  defective  external  abdominal  ring  ;  both 
pillars  are  imperfectly  developed.     (After  Felizet.) 


side,  so  that  the  whole  of  this  part  of  the  abdominal  wall 
appears  to  be  badly  developed.  The  intercolumnar  fascia, 
too,  is  frayed  out  and  badly  developed.  Defective  pillars 
are  characterised  by  feeble  development  of  the  outer  pillar, 
which  is  not  uncommon  (fig.  47) ;  of  the  inner  pillar  of 
rarer  occurrence  (fig.  48) ;  or  of  both  pillars  (fig.  49). 

The  tunica  vaginalis  in  a  child  ought  to  be  completely 
separated  from  the  general  peritoneal  cavity  by  a  more  or 
less  complete  fibrous  cord  ;  but  this  separation,  as  Fere  has 
shown,  is  often  incomplete.  In  its  slightest  form  the 
canal  in  the  processus  vaginalis  may  be  almost  completely 


4IO      THE    SURGICAL    DISEASES    OF    CHILDREN 

absent,  except  for  a  small  funnel-shaped  depression  at  its 
upper  part ;  in  its  worst  form  the  tunica  vaginalis  may 
retain  the  foetal  condition  seen  in  fig.  50,  and  be  in  direct 
connection  with  the  peritoneum  by  a  widely  open  canal. 
The  prolapsed  intestine  may  pass  into  the  unclosed  tunica 
vaginalis,  and  a  congenital  hernia  may  be  produced  in 
which  the  gut  lies  immediately  above  the  testes,  and 
in  the  same  sac.  The  funicular  portion  of  the  tunica 
vaginalis  may  be  shut  off  from  the  lower  part  of  the  sac, 
whilst  its  upper  part  is  continuous  with  the  peritoneum  ; 

•sv. 


Fig.  50.— Processus  vaginalis  about  the  end  of  the  eighth  month  of  intra- 
uterine life.  Ep.,  Epididymis  ;  Gb.,  gubernaculum ;  S.V.,  spermatic  vessels; 
Test.,  testicle;  V.D.,  vas  deferens. 

[Block  kindly  lent  by  Mr.  C.  B.  Locfcwood.] 

the  intestine  passing  into  the  unclosed  portion  then  forms 
a  funicular  hernia  :  these  are  the  two  common  types  of 
hernia  in  children.  The  ordinary  form  of  inguinal  hernia 
found  in  adults,  in  which  there  is  a  separate  sac,  as  well 
as  the  encysted  or  infantile  hernia,  also  occur  in  children, 
but  much  more  rarely. 

The  most  important  varieties  of  inguinal  hernia  in 
children  are  those  in  which  a  scrotal  rupture  is  associated 
with  an  undescended  testis  ;  or  its  presence  is  masked 
by  a  hydrocele,  or  by  a  cystic  enlargement  of  the  sac. 


HERNIA    AND    ITS    TREATMENT  4II 

The  exciting  causes  which  convert  a  potential  into  an 
actual  hernia  are  very  numerous  :  coughing,  straining, 
difficulties  in  micturition  and  defecation,  associated  with 
the  weakness  and  relaxation  of  the  tissues  produced  by 
the  various  exhausting  and  wasting  diseases  of  childhood, 
are  amongst  the  more  frequent.  The  rupture  is  apparent 
in  nearly  half  the  cases  within  the  first  year  after  birth, 
and  more  than  a  quarter  of  the  remainder  appear  between 
the  twelfth  and  the  thirtieth  months,  often  as  a  result  of 
measles,  whooping  cough,  and  chronic  bronchitis ;  whilst 
the  remainder  appear  later,  either  from  similar  causes,  from 
a  violent  effort,  or  during  convalescence  from  a  severe 
illness  in  children  with  a  family  history  of  weakness  in 
the  abdominal  wall. 

Diagnosis. — The  diagnosis  of  inguinal  hernia  is  so 
obvious,  and  its  signs  are  so  well  known,  that  it  would  be 
superfluous  to  dilate  upon  them.  It  should  be  remembered 
that,  owing  to  the  anatomical  peculiarities  iu  children 
(p.  405),  the  hernia  is  often  situated  much  higher  in  the 
abdominal  wall  than  is  usual  in  adults ;  that  it  has 
somewhat  less  tendency  to  become  scrotal,  and,  above 
all,  that  it  has  a  troublesome  habit  of  completely  dis- 
appearing, so  that  the  most  careful  manipulation  fails  to 
detect  any  sign  of  its  presence.  Such  hernia?  usually  re- 
appear with  as  great  facility  as  they  have  vanished,  so  that 
the  surgeon  should  not  be  too  positive  as  to  the  condition 
of  a  child  reported  to  be  ruptured,  because  he  finds  no 
trace  of  it,  and  because  the  abdominal  rings  and  the  canal 
appear  to  him  to  be  normal,  except  for  a  slight  degree  of 
enlargement. 

The  presence  of  a  small  rupture  may  be  masked  by  the 
co-existence  of  a  hydrocele  or  of  a  displaced  testiclo.  The 
hydrocele  is  smooth  and  tense,  whilst  the  rupture  is  often 
s  ift  and  irregular,  and  in  every  case  of  suspected  rupture 


412      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  surgeon  should  make  a  routine  examination  of  the 
testicles  to  assure  himself  of  their  exact  position,  and  he 
will  thus  escape  many  pitfalls. 

Contents  of  Hernial  Sac. — The  hernial  sac  usually 
contains  one  or  more  loops  of  the  small  intestine,  more 
rarely  omentum  only  is  present.  The  vermiform  appendix 
alone  or  in  conjunction  with  the  ceecum  is  found  with  toler- 
able frequency  in  the  rupture ;  the  ovary  and  the  other 
abdominal  viscera  are  of  much  rarer  occurrence. 

Differential  Diagnosis. — A  hernia  has  to  be  distin- 
guished from  a  hydrocele,  either  ordinary  or  encysted ; 
from  an  abscess  or  a  cyst  occupying  the  inguinal  canal ; 
from  enlarged  and  inflamed  lymphatic  glands;  from  a 
retained  testicle ;  and  from  the  lobed  masses  of  fat  which 
sometimes  surround  the  spermatic  cord. 

Prognosis. — The  prognosis  varies  with  the  character 
and  cause  of  the  rupture.  Some  congenital  hernise  in  very 
young  children  are  undoubtedly  cured  spontaneously,  even 
when  no  truss  has  been  applied,  but  very  many  either 
remain  stationary  or  become  larger  if  they  are  left  un- 
treated. Spontaneous  cure  seems  to  be  more  frequent  in 
cases  of  congenital  and  scrotal  hernise  than  in  those  which 
have  appeared  in  the  later  years  of  childhood,  or  during 
convalescence  from  one  of  the  exhausting  diseases.  We 
are  ignorant  of  the  means  by  which  a  spontaneous  cure  is 
effected,  though  it  is  probably  by  a  continuance  of  those 
natural  processes  which  ought  to  have  been  completed 
before  the  birth  of  the  child. 

Sequelae. — Irreducible  hernise  are  met  with  occasion- 
ally in  children,  but  they  are  much  less  frequent  than  in 
persons  of  mature  age.  Acute  strangulation  is  by  no 
means  uncommon,  and  is  attended  by  the  ordinary  signs 
and  symptoms  of  the  condition.  It  presents,  however, 
certain  peculiar  features  which  are  not  usually  found  in 


HERNIA    AND    ITS    TREATMENT  413 

adults.  The  bowel,  even  in  acute  strangulation,  can  nearly 
always  be  reduced  by  properly  applied  taxis ;  and  in  the 
very  rare  cases  in  which  herniotomy  has  to  be  performed, 
the  smallest  possible  incision  of  the  point  of  constriction 
is  sufficient  to  allow  ready  reduction ;  whilst  it  often 
happens  that  the  prolapsed  intestine  can  be  replaced  as 
soon  as  the  ring  is  exposed,  without  any  division  of  its 
deeper  tissues. 

Treatment. — The  treatment  of  hernia  in  children  is 
either  by  the  use  of  a  truss  or  by  an  operation.  A  certain 
proportion  of  children  can  be  cured  by  the  systematic  and 
long-continued  use  of  a  truss ;  and  this  method  should 
therefore  be  adopted  in  every  case,  unless  it  is  clearly 
contra-indicated.  It  has,  however,  for  too  long  a  time 
been  emploj'ed  to  the  exclusion  of  the  operation  for  radical 
cure.  The  operation  for  radical  cure  was  practised  by 
Sermesius,  who  says  that  he  learnt  it  from  a  Russian 
feldherr,  or  apothecary,  at  the  end  of  the  seventeenth 
century.  Freitage  in  Switzerland  followed  Sermesius' 
treatment,  and  Heister  {Surgery,  1768,  pt.  ii.,  sect.  5,  §  12) 
strongly  recommends  the  method. 

Palliative. — The  trusses  in  common  use  in  this  country 
are  the  skein  of  white  Berlin  wool,  which  is  useful  for 
children  so  long  as  they  wear  diapers.  It  keeps  the  hernia 
up,  is  cheap,  can  be  constantly  changed,  and  does  not  cause 
excoriation.  It  probably  has  no  curative  action  ;  but  if  it 
be  conscientiously  applied,  it  prevents  the  parts  becoming 
over-dilated,  by  not  allowing  the  bowel  to  be  constantly 
passing  in  and  out  of  the  sac,  and  so  allows  of  the  comple- 
tion of  those  developmental  changes  which  should  have 
been  intra-uterine.  Mr.  William  Coates,  of  Wrington,  in 
Somerset,  first  called  attention,  on  Sept.  4,  1848,  to  the 
use  of  the  woollen  truss  in  the  hernia  of  infants,  saying 
that  he  had  learnt  it  from  a  gudewifo  in  his  neighbour- 


414      THE    SURGICAL    DISEASES    OF    CHILDREN 

hood.  "  It  consists  simply  of  a  skein  of  lamb's  wool ;  for 
infants,  Berlin  wool  is  preferable.  This  encircles  the 
pelvis,  one  end  being  passed  through  the  other  at  a  point 
corresponding  with  the  inguinal  ring ;  the  free  end  is 
carried  between  the  thighs,  and  is  fastened  behind  to  that 
portion  which  forms  the  cincture.  This  simple  and  cheap 
contrivance  can  be  worn  during  the  morning  and  evening 
ablutions,  and  then  changed  for  a  dry  one.  No  attention 
is  required  on  the  part  of  the  nurse,  except  at  the  moment 
of  changing.  With  ordinary  care  in  drying  the  skin,  and 
the  occasional  application  of  magnesia  or  other  nursery 
powders,  I  have  never  seen  the  skin  galled." 

In  older  children  a  truss  of  rubber  with  an  air-pad  is 
frequently  employed.  It  has  the  advantage  of  being 
washable ;  but  its  pad  is  not  firm,  and  it  frequently  causes 
excoriation.  The  ordinary  spring  truss,  made  by  a  com- 
petent mechanician  under  the  immediate  supervision  of 
the  surgeon  and  adopted  to  the  individual  case,  is  alone 
of  service  as  a  method  of  curative  treatment.  It  cannot 
usually  be  worn,  however,  until  the  child  is  at  least  a 
year  old ;  it  has  to  be  constantly  renewed  as  the  child 
grows.  It  is  expensive,  and,  except  under  very  excep- 
tional conditions,  it  cannot  be  kept  in  place  in  a  healthy 
child  who  has  learnt  to  walk  and  play. 

The  most  persistent  use  of  a  truss  will  in  many  cases 
only  prevent  the  rupture  from  coming  down,  and  can 
therefore  only  be  palliative  ;  but  it  may  actually  cure  the 
hernia  if  the  rings  are  well  formed,  though  they  may  be 
unduly  dilatable,  if  the  hernia  is  small,  and  the  canal 
is  free,  i.e.  when  it  does  not  contain  either  a  cyst,  a  hydro- 
cele, or  a  retained  testis.  A  truss  is  useless,  and  time  is 
wasted  in  its  application,  in  cases  where  the  hernia  is  large, 
when  the  pillars  are  badly  developed,  when  there  is  a 
retained  testis,  and  when  the  hernia  is  irreducible.     There 


HERNIA    AND    ITS    TREATMENT  415 

exist,  on  the  other  hand,  a  class  of  doubtful  eases  in  which 
a  Large  abdominal  ring  readily  admits  the  linger  of  the 
surgeon,  and  allows  it  to  pass  into  the  abdominal  cavity 
without  an}*  sense  of  resistance  being  felt  from  the  abdo- 
minal walls,  when  the  pillars  of  the  ring  feel  soft  and 
membranous,  and  when  they  do  not  approach  each  other  if 
the  child  cries  or  strains.  A  truss  may  fairly  be  tried  in 
these  doubtful  cases  before  a  radical  operation  is  pro- 
posed. 

A  truss  should  be  worn  night  and  day  for  nearly  a  year, 
if  it  is  decided  to  adopt  this  method  of  treatment.  The 
child  should  be  made  to  lie  down  daily  flat  upon  its  back 
for  two  or  three  hours,  and  it  should  be  taken  into  the 
open  air  whenever  the  weather  is  suitable.  It  may  be 
allowed  to  walk,  but  such  exercise  must  not  be  carried  to 
fatigue.  Good  food  in  its  most  digestible  forms  must  be 
given,  and  the  greatest  care  must  be  taken  to  keep  the 
bowels  in  such  a  state  as  will  lead  to  the  least  possible 
straining  during  the  passage  of  a  motion.  Some  hernise 
may  be  cured  by  these  means,  the  pillars  becoming  firm 
and  tense,  and  the  funicular  process  closed  ;  but  it  should 
not  be  assumed  that  because  the  rupture  has  disappeared 
it  is  necessarily  cured,  for  it  often  happens  that  such 
apparent  cures  result  in  a  reappearance  of  the  hernia, 
sometimes  at  a  critical  moment,  and  such  relapsed  hernise 
are  attended  by  all  the  dangers  of  an  acute  rupture. 

The  child  may  be  considered  permanently  and  not  appa- 
rently cured  when,  after  the  rigorous  use  of  a  truss,  the 
pillars  are  found  to  be  approximated,  when  there  is  no 
sensation  of  impulse  if  the  child  coughs  or  strains,  and  if 
the  patient  passes  through  an  attack  of  whooping  cough 
without  the  rupture  reappearing.  The  method  by  which 
a  truss  cures  a  rupture  is  as  uu known  as  that  by  which  a 
spontaneous  cure  is  effected,  and  we  can  only  assume  that 


41 6      THE    SURGICAL    DISEASES    OE    CHILDREN 

it  is  the  result  of  a  slight  irritation  of  the  neck  of  the  sac 
which  leads  to  its  gradual  obliteration. 

Operative. — The  radical  operation  for  the  cure  of  hernia 
has  been  very  frequently  employed  during  the  last  few 
years,  but  we  still  need  more  evidence  of  its  ultimate 
effect,  as  it  is  too  soon  to  dogmatise.  It  is  applicable 
to  any  age,  from  the  earliest  infancy  to  puberty,  though 
there  are  many  surgeons  who  prefer  to  wait  until  the  child 
has  reached  four  years  of  age  before  they  undertake  it. 
I  have  no  hesitation,  however,  in  considering  its  advisa- 
bility in  every  case  of  congenital  hernia  in  which  the 
methodical  and  sufficient  application  of  a  truss  has  failed 
to  effect  a  cure ;  when  after  such  use  of  a  truss  the  ring 
remains  unduly  large  as  compared  with  that  on  the  oppo- 
site side,  even  though  the  rupture  has  not  descended. 
The  operation  should  in  my  opinion  be  performed  in  all 
cases  in  which  the  rings  are  badly  developed,  when  the 
rupture  is  complicated  with  a  retained  testis,  and  when 
the  sac  appears  to  contain  adherent  omentum.  The 
radical  operation,  except  in  cases  of  acute  strangulation, 
is  always  one  of  expediency;  but  the  danger  is  so  slight, 
the  relief  is  so  great  and  immediate,  and  the  failures  are 
so  few,  that  I  perform  the  operation  more  and  more  fre- 
quently, and  each  time  with  a  sense  of  increasing  satisfac- 
tion. The  good  results  are  obtained  even  in  the  youngest 
children ;  but  the  operation  should  not  be  performed 
in  very  feeble  babies,  during  the  acute  stage  of  rickets 
marked  by  intestinal  disturbances,  when  there  is  active 
tuberculous  disease  of  the  bones  or  joints,  or  during  con- 
valescence from,  or  the  prevalence  of,  the  exanthemata. 

The  operation  is  performed  earlier  upon  the  children  of 
the  poor  than  of  the  rich,  and  in  slighter  cases  of  rupture, 
because  amongst  the  poor  less  personal  attention  can  be 
given  to  the  children,  and  trusses  are  allowed  to  chafe  the 


HERNIA    AND    ITS    TREATMENT  4 1  7 

skin,  for  they  are  apt  in  such  neglected  cases  to  be  worn 
over  an  unreduced  hernia. 

The  child  is  kept  in  bed  for  a  few  days  to  accustom  it  to 
restraint,  and  the  operation  is  preceded  by  a  thorough 
cleansing  of  the  thighs  and  abdomen,  and  the  application 
over-night  of  an  antiseptic  dressing.  At  the  time  of  the 
operation  the  exact  position  of  the  external  abdominal  ring 
is  determined  by  invaginating  the  scrotum,  and  an  incision 
is  made  through  the  abdominal  wall  in  such  a  manner  as 
to  expose  it.  The  ordinary  oblique  incision  may  be  used, 
and  is  necessary  in  cases  of  strangulation,  and  if  the  testis 
is  retained  in  the  canal ;  but  for  ordinary  cases  of  uncom- 
plicated hernia  Dr.  Felizet  recommends  that  the  incision 
should  be  transverse,  as  the  branches  of  the  superficial 
external  pudic  artery  then  escape  division,  and  the  wound 
is  almost  bloodless.  The  tissues  are  divided  until  the 
aponeurosis  of  the  external  oblique  comes  well  into  view, 
and  this  often  lies  at  a  considerable  depth,  for  the  front 
of  the  child's  abdomen  is  covered  with  a  very  thick  layer 
of  fat.  The  aponeurosis  is  very  dense,  so  that  there  is 
no  likelihood  of  overlooking  it,  or  of  cutting  through  it 
inadvertently. 

An  assistant  maintains  a  firm  hold  of  the  testicle  in  the 
scrotum  as  soon  as  the  preliminary  incision  has  been  made, 
and  the  edges  of  the  transverse  incision  are  carefully 
retracted  until  the  spermatic  cord  is  seen.  The  cord  is 
enclosed  in  a  common  fibrous  sheath,  which  contains  the 
hernial  sac  and  the  elements  of  the  cord.  The  assistant, 
by  pulling  the  testicle  downwards,  stretches  the  cord, 
whilst  the  surgeon  divides  the  fibrous  sheath  longitudi- 
nally, and  looks  for  the  hernial  sac.  The  sac  is  not  always 
easy  to  find,  for  in  children  the  knuckle  of  intestine  is  not 
often  in  it  at  the  time  of  the  operation,  and  it  is  so  small 
and  thin  that  it  is  readily  overlooked  by  those  unaccus- 

E    E 


4l8      THE    SURGICAL    DISEASES    OF    CHILDREN 

tomed  to  see  it.  It  usually  lies  to  the  inner  side  and  in 
front  of  the  spermatic  cord,  although  its  position  is  by  no 
means  constant,  and  its  bluish  white  colour  is  usually  a 
guide  to  its  presence. 

The  next  step  in  the  operation  is  to  seize  the  sac  in  a 
pair  of  pressure-forceps,  and  then  to  isolate  it — proceedings 
which  are  materially  assisted  by  a  clean  division  of  the 
fibrous  sheath  and  cremaster  muscle  surrounding  the 
spermatic  cord.  The  greatest  care  and  gentleness  must 
be  exercised  in  separating  the  sac,  as  the  pampiniform 
plexus  of  veins,  the  vas  deferens,  and  the  spermatic  artery 
are  so  intimately  connected  with  it  that  they  have  actually 
to  be  peeled  off,  and  in  doing  this  there  is  the  greatest 
danger  of  injuring  them.  The  separation  is  facilitated  if 
the  assistant  keeps  the  cord  tense  by  pulling  the  testicle 
gently  downwards  in  the  scrotum,  and  the  sac  is  usually 
less  blended  with  the  other  constituents  of  the  cord  at  its 
upper  than  at  its  lower  part,  so  that  the  surgeon  begins 
the  separation  near  the  external  abdominal  ring,  and 
expects  to  find  the  vessels  on  the  outer  side  of  the  sac,  and 
the  vas  either  in  front  or  behind  it.  The  vas  deferens  in 
children  is  extremely  small,  and  in  babies  is  about  as  large 
as  a  capillary  vaccine  tube. 

The  sac  is  laid  open  as  soon  as  it  has  been  isolated,  the 
same  care  being  exercised  and  the  same  methods  adopted  as 
are  usual  in  dividing  the  sheath  of  an  artery  before  liga- 
turing it  in  its  continuity.  The  tip  of  the  little  finger 
is  then  introduced  into  the  sac,  first  downwards  towards 
the  testicle,  and  then  upwards  into  the  abdomen  to  deter- 
mine the  nature  of  the  hernia  and  the  emptiness  of  its  sac. 
The  entire  hernial  sac  may  be  turned  out  of  the  scrotum 
in  a  few  cases,  but  it  happens  much  more  frequently  that 
the  rupture  is  congenital  and  the  sac  is  the  tunica  vagi- 
nalis itself.     As  soon  as  the  middle  portion  of  the  sac  has 


HERNIA    AND    ITS    TREATMENT  419 

been  isolated  in  a  congenital  hernia,  a  ligature  of  catgut  is 
tied  round  it  below  the  pressure-forceps,  and  the  sac  is  cut 
across  after  the  surgeon  has  satisfied  himself  that  he  is 
dealing  with  the  sac,  and  sac  only,  and  that  he  has  not 
included  the  artery  or  the  vas  in  his  ligature.  The  lower 
end  slips  back  into  the  scrotum  to  form  the  new  tunica 
vaginalis  testis.  The  upper  part  of  the  sac  is  then  exposed 
by  holding  its  cut  end  out  of  the  wound  by  means  of  the 
pressure-forceps,  and  its  neck  is  drawn  downwards  and 
ligatured  with  a  simple  loop  of  catgut  tied  with  a  reef 
knot  in  young  children  where  the  sac  is  very  thin ;  in 
older  children  the  neck  of  the  sac  is  transfixed  and  tied 
with  a  pedicle  ligature  or  with  a  Staffordshire  knot,  care 
again  being  taken  that  the  neck  of  the  sac  only  is  tied, 
and  that  the  neighbouring  tissues  are  not  included  in  the 
ligature.  The  sac  is  then  cut  away  about  half  an  inch 
below  the  ligature,  and  it  disappears  into  the  abdominal 
cavity,  leaving  the  surgeon  free  to  deal  with  the  inguinal 
canal  and  its  pillars. 

The  method  of  treating  the  sac  is  varied  in  older  chil- 
dren, for  in  them  it  is  stouter,  and  can  be  manipulated 
with  greater  ease.  In  these  cases  I  usually  adopt  the 
method  recommended  by  my  friend  Mr.  C.  B.  Lockwood. 
The  cut  end  of  the  sac  is  twisted  and  pulled  downwards 
by  means  of  the  pressure-forceps  attached  to  it.  It  is  then 
transfixed  by  a  Macewen's  needle,  provided  with  a  handle 
like  the  ordinary  "  button-hook  "  (fig.  51),  armed  with  a 
loop  of  aseptic  silk.  This  ligature  is  tied  tightly  round 
the  sac  in  a  Staffordshire  knot  by  throwing  the  loop  over 
the  pressure-forceps,  and  thus  round  the  sac,  bringing  one 
end  of  the  ligature  above  the  loop  and  the  other  below  it, 
and  then  tying  the  ends  in  a  reef  knot,  so  as  to  include 
the  loop,  and  compress  both  halves  of  the  transfixed  sac. 
Each  end  of  the  ligature  is  then  separately  passed  through 


420      THE    SURGICAL    DISEASES    OF    CHILDREN 

the  eye  of  the  Macewen's  needle,  which  is  then  made  to 
traverse  the  fascia  transversalis  from  within  outwards, 
the  arcuate  fibres  of  the  internal  oblique  and  transversalis 
muscles,  and  the  aponeurosis  of  the  external  oblique,  but 
not  the  skin.  The  ends  of  the  ligature  are  brought 
through  at  two  different  points,  so  that  when  they  are 
tied  together  the  stump  of  the  sac  is  drawn  up  and  fixed 
beneath  the  arcuate  fibres.  If  a  testis  be  retained,  it  must 
either  be  removed  or  sutured  to  the  bottom  of  the  scrotum, 
as  the  surgeon  considers  proper  (see  p.  479). 

The  operation  is  completed  in  children  by  suturing  the 
pillars  of  the  ring  so  as  only  to  allow  room  for  the  passage 
of  the  spermatic  cord.     Three  sutures  of  silver  wire  are 


Pig.  51.— Macewen's  Needle,  employed  in  the  operation  for  the  radical  cure 
of  hernia. 

usually  sufficient,  the  highest  one  being  inserted  first,  and 
care  being  taken  to  avoid  including  the  cord  or  injuring  it 
whilst  they  are  passed.  The  wound  is  thoroughly  flushed 
with  a  1  in  2000  solution  of  the  perchloride  or  the  bin- 
iodide  of  mercury,  and  the  skin  is  then  brought  together 
with  sutures  of  horsehair ;  and  as  it  is  essential  to  obtain 
union  by  first  intention,  no  drainage-tube  is  employed.  The 
dressing  consists  of  a  layer  of  antiseptic  gauze— preferably 
cyanide— with  a  thick  pad  of  absorbent  wool  kept  in  place 
by  a  double  spica  bandage  of  gauze.  A  square  piece  of 
red  hat-lining  sufficiently  large  to  cover  both  groins,  and 
to  extend  as  high  as  the  navel,  is  laid  over  the  gauze  spica, 
and  the  penis  is  drawn  through  a  hole  in  its  centre.     This 


HERNIA    AND    ITS    TREATMENT  42  I 

protection  is  kept  in  place  by  a  double  spica  of  flannelette. 
The  dressing  should  not  be  changed  more  often  than  is 
necessary,  and  a  week  may  be  allowed  to  elapse  before  it 
is  touched.  Although  the  wound  heals  well  as  a  rule,  yet 
it  should  be  examined  from  time  to  time,  because  here,  as 
in  all  other  surgical  diseases  of  children,  neither  sensations 
of  pain  nor  the  indications  of  the  thermometer  can  be 
trusted  in  the  same  way  as  in  adults  to  afford  evidence  of 
clinical  value.  Absence  of  pain  by  no  means  implies  that 
everything  is  going  well  with  the  wound,  for  a  very 
slight  constitutional  disturbance  may  cause  a  great  rise  of 
temperature,  whilst  a  severe  local  inflammation  may  have 
no  effect  upon  the  general  body  heat.  The  skin  wound  is 
usually  soundly  healed  in  a  week  or  ten  days,  but  the 
child  should  be  kept  in  bed  for  a  month,  and  at  the  expi- 
ration of  that  time  it  may  be  allowed  to  go  about.  Exami- 
nation of  the  scrotum  will  often  show  that  it  contains  a 
swollen  cylinder,  which  represents  the  indurated  cord  and 
tunica  vaginalis  ;  but  this  slowly  disappears,  and  I  have 
never  seen  any  ill-effects  from  it.  When  the  hernia  is 
double,  it  is  better  to  allow  an  interval  of  three  weeks  to 
elapse  between  the  two  operations. 


CHAPTER  XX 

DISEASES  AND   MALFORMATIONS   OF 
THE   RECTUM 

PROLAPSE  OF   THE  RECTUM.47 

-Etiology. — Prolapse  of  the  rectum  and  anus  takes  place 
in  children  with  great  frequency.  This  appears  to  be  due 
in  part  to  the  fact  that  the  upper  portion  of  the  rectum 
is  more  movable  than  the  lower ;  in  part  to  the  fact  that 
the  sacrum  is  nearly  straight  in  children  ;  and  in  part 
because  they  strain  much  more  than  adults  in  passing 
their  motions.  Dr.  Jacobi  thinks  this  straining  can  be 
explained  anatomically  by  the  presence  of  two  or  three 
angular  flexures  often  seen  in  the  lower  part  of  the  colon 
of  a  child.  No  prolapse  occurs  so  long  as  the  floor  of  the 
perineum  remains  firm  and  the  sphincter  contracts  well. 
The  prolapse  in  the  earlier  stages  is  slight,  and  only 
occurs  during  defecation  ;  but  it  tends  to  increase  in  size 
and  become  permanent  if  precautionary  measures  be  not 
adopted.  The  condition  is  often  associated  with  general 
feebleness,  chronic  intestinal  catarrh,  thread-worms 
(oxyuris),  phimosis,  spasmodic  cough,  and  more  rarely 
with  stone  in  the  bladder,  or  with  a  rectal  polypus. 
These  causes  should  be  first  alleviated  or  removed. 

Treatment. — Medical  treatment  in  the  vast  majority 
of  cases  of  prolapse  will  effect  a  cure,  and  I  usually  re- 
commend that  adopted  by  Mr.  Allingham.      The  child  is 

422 


DISEASES    OF    THE    RECTUM  423 

to  be  kept  in  bed,  and  all  its  motions  are  to  be  passed 
lying  npon  its  left  side  at  the  edge  of  the  bed,  the  right 
buttock  being  drawn  to  one  side  by  the  nurse  during  the 
passage  of  the  faeces,  as  the  anal  orifice  is  thereby  tight- 
ened, and  there  is  less  chance  of  the  bowel  being  pro- 
truded. The  parts  are  then  to  be  well  washed  with  cold 
water,  and  if  prolapse  has  occurred,  they  are  afterwards 
to  be  sponged  with  an  astringent  solution  of  a  drachm  of 
alum  in  a  pint  of  decoct,  quercus.  The  bowel  should 
then  be  gently  returned.  Drachm  doses  of  the  compound 
liquorice  powder  may  be  given  as  a  laxative  if  it  is  re- 
quired. The  injection  of  a  minim  of  the  injectio  hypo- 
derm,  strychnise  nitratis  or  the  t£q  of  a  grain  of  citrate 
of  ergotinine  into  the  rectal  wall  is  also  said  to  act  bene- 
ficially in  these  cases  by  increasing  the  tonic  contraction 
of  the  sphincter. 

When  the  prolapse  is  not  improved  by  these  measures, 
more  severe  ones  have  to  be  adopted  ;  and  I  usually  dissect 
off  a  spiral  strip  of  mucous  membrane,  taking  care  not  to 
cut  deeply  into  the  submucous  tissue,  lest  the  haemorrhage 
be  severe.  In  a  few  cases  I  have  painted  the  mucous  mem- 
brane with  strong  nitric  acid,  afterwards  brushing  it  over 
with  olive  oil ;  but  this  method  is  accompanied  by  so 
much  pain  and  straining,  that  I  prefer  the  former. 

The  bowel  in  either  case  must  be  thoroughly  emptied 
before  the  operation,  an  anaesthetic  must  be  given,  and 
the  anus  should  be  well  dilated.  The  mucous  membrane 
must  be  dried  before  the  nitric  acid  is  applied,  and  care 
should  be  taken  not  to  touch  the  skin  or  margins  of  the 
anus  with  the  acid.  After  it  lias  been  applied,  the  surface 
of  the  bowel  should  be  thoroughly  oiled,  and  a  pad  of  oiled 
lint  should  also  be  introduced  into  the  rectum. 

The  operation  of  colopexy,  or  the  cure  of  the  prolapse 
by  the  formation  of  artificial  adhesions,  has  recently  been 


424      THE    SURGICAL    DISEASES    OF    CHILDREN 

suggested  and  practised  for  the  worst  forms  of  prolapse  ; 
fortunately,  however,  these  do  not  often  occur  in  children, 
and  I  have  had  no  opportunity  of  trying  it.  The  operation 
is  performed  through  the  same  abdominal  incision  as  for 
inguinal  colotomy.  The  rectum  is  found  by  tracing  the 
colon  downwards  ;  it  is  pulled  straight  so  as  to  overcome 
any  tendency  to  prolapse,  its  muscular  walls  are  sutured 
to  the  deeper  parts  of  the  wound,  and  the  skin  wound  is 
closed.  Verneuil's  operation,  modified  by  Dr.  Gerard 
Marchant,  consists  in  exposing  the  rectum  posteriorly 
beneath  the  coccyx  and  then  suturing  its  walls.  The 
operation  is  described  with  diagrams  in  the  Bull,  et  Mdm. 
de  la  Soc.  de  Chirurgie,  xvi.  p.  828,  and  xviii.  p.  153. 

RECTAL  ADENOMATA. 

(1)  Single.  Morbid  Anatomy. —  The  rectal  adeno- 
mata or  polypi  in  children  are  visually  single.  They  are 
small  and  soft  tumours,  generally  with  a  smooth  surface 
and  nearly  always  pedunculated.  The  pedicle  is  often  so 
thin  that  it  may  be  ruptured  whilst  the  child  is  straining 
at  stool,  and  so  the  polypus  maybe  spontaneously  expelled. 
They  are  more  often  situated  upon  the  posterior  than  upon 
the  anterior  wall  of  the  rectum,  and  are  within  one  and  a 
half  to  three  inches  of  the  anus.  They  are  usually  true 
adenomata,  consisting  of  Lieberkuhn's  crypts  grouped 
irregularly  in  a  stroma  of  fibrous  tissue ;  but  cystic, 
fibrous,  and  dermoid  (p.  515)  polypi  occur  as  pathological 
curiosities. 

Symptoms. — The  symptoms  are  often  obscure,  and 
bleeding  may  first  give  evidence  of  their  presence.  The 
bleeding  is  very  slight  at  first,  but  afterwards  it  becomes 
more  abundant,  though  it  is  only  in  very  rare  cases  that 
it  is  of  any  importance  ;  it  is  often  accompanied  by  a  glairy 
discharge  of  mucus. 


DISEASES    OF    THE    RECTUM  425 

Diagnosis. — The  diagnosis  is  readily  made  by  a  digital 
examination  of  the  rectum,  a  mode  of  investigation  which 
should  never  be  omitted  in  cases  of  prolapse,  fissure,  and 
purulent  discharge  from  the  rectum,  for  these  are  the 
conditions  most  often  associated  with  rectal  polypi. 

Treatment. — The  treatment  in  the  pedunculated  forms 
is  to  twist  them  off;  but  if  the  pedicle  be  short  or  thick, 
it  is  better  to  place  the  child  under  an  ansesthetic,  and  to 
ligature  the  polypus  after  the  anus  has  been  dilated. 

(2)  Multiple. — Rectal  polypi  in  rare  cases  are  multiple 
and  diffuse.  Such  multiple  polypi  occasionally  occur  in 
several  members  of  the  same  family,  and  the  irritation 
which  they  produce  may  give  rise  to  an  adenoid  cancer 
whilst  the  patient  is  yet  under  twenty  years  of  age. 
Cancer  of  the  rectum  occasionally  occurs  in  young  adults, 
independently  of  such  growths.  It  is  necessary  to  excise 
in  these  cases  ;  but  they  are  so  unusual  that  I  have  never 
had  occasion  to  resort  to  the  operation. 

BILHARZIA  ADENOMATA. 

Children  in  Egypt  sometimes  present  multiple  rectal 
adenomata  due  to  the  irritation  produced  by  the  ova  of 
Bilharzia  hsematobia.  These  growths  have  been  carefully 
examined  by  Dr.  Mackie,  of  Alexandria,  through  whose 
kindness  I  have  had  opportunities  of  seeing  several 
specimens. 

Pathology. — The  tumours  are  true  fibro-adenomata  and 
they  are  very  vascular.  Abundance  of  ova  are  found  in  the 
tissue,  and  the  vessels  running  from  the  tumour  contain 
fertilised  eggs,  ready  for  hatching  in  the  blood  stream  in 
which  the  adult  females  are  found. 

Symptoms.  —  There  is  considerable  rectal  tenesmus, 
in   addition  to   bleediug   from  the    bowel,  and   diarrhoea. 


426      THE    SURGICAL    DISEASES    OF    CHILDREN 

Hematuria  is  a  frequent  symptom ;  but  even  when  the 
urine  is  clear,  Bilharzia  ova  may  be  found  in  it.  The  child 
long  survives  the  symptoms,  and  leads  a  miserable  ex- 
istence until,  worn  out  by  pain  and  reduced  by  anaemia, 
it  dies. 

Diagnosis. — Digital  examination  of  the  rectum,  with 
microscopical  examination  of  the  urine,  is  sufficient  to 
establish  the  diagnosis. 

Treatment. — The  treatment  is  necessarily  prophy- 
lactic, for  the  lesions  are  so  widely  spread  along  the 
genito-urinary  tract  that  no  local  remedies  are  of  the  least 
service. 

NJEVI   OF   THE  RECTUM. 

Nasvi  occur  in  the  rectum  as  pathological  curiosities. 
Mr.  Marsh  has  reported  one  which  he  treated  in  a  girl 
of  ten.     It  gave  rise  to  haemorrhage  from  the  bowel. 

CONGENITAL  IMPERFECTIONS  OF  THE 

RECTUM.4* 

Varieties. — Cases  of  congenital  imperfections  of  the 
rectum  are  brought  under  the  notice  of  the  surgeon  with 
sufficient  frequency  to  put  a  serious  strain  upon  his 
surgical  resources.  The  chief  varieties  of  malformation 
are:  (1)  Imperforate  anus  (atresia  ani),  the  rectum  being 
partially  (atresia  recti)  or  wholly  deficient  (atresia  ani 
et  recti),  the  fold  of  the  scrotum  extending  backwards  in 
an  unbroken  line  to  the  coccyx.  (2)  The  anus  opening 
into  a  cul-de-sac,  the  rectum  being  wholly  deficient,  or 
being  separated  from  the  bowel  by  a  thin  membrane, 
which  is  either  complete  or  is  perforated  to  a  greater  or 
less  extent  at  its  centre.  (3)  Imperforate  anus  in  the 
male,  the  rectum  being  partially  or  wholly  deficient,  and 


DISEASES    OF    THE    RECTUM  427 

communicating  with  the  prostatic  portion  of  the  urethra 
(atresia  ani  urethralis),  or  with  the  bladder  (atresia  ani 
vesicalis^),  at  its  base.  (4)  Imperforate  anus  in  the  female, 
the  rectum  being  partially  deficient  and  communicating 
•with  the  posterior  wall  of  the  vagina  just  in  front  of  the 
hymen  (atresia  ani  vaginalis).  (5)  Imperforate  anus,  the 
rectum  being  partially  deficient,  and  opening  externally 
by  a  narrow  outlet  in  an  abnormal  situation  (atresia  ani 
perinealis  aut  scrotalis).  (6)  The  anus  and  rectum  may  be 
well  formed  and  of  normal  size,  but  the  outlet  is  obstructed 
by  a  fold  of  skin  extending  from  the  scrotum  to  the  tip 
of  the  coccyx.  A  small  opening  may  exist  on  one  or  both 
sides  of  this  fold. 

Cause. — The  cause  of  the  condition  is  well  known  to  be 
due  to  a  failure  of  the  rectal  invagination  or  proctodseum 
to  effect  a  junction  with  the  cloacal  section  of  the  ali- 
mentary canal.  The  condition  in  which  the  rectum  ter- 
minates in  the  genito-urinary  tract  is  the  result  of  a 
further  error  in  the  developmental  process,  for  in  these 
cases  the  cloaca  has  not  been  completely  divided  into  its 
urino-genital  and  intestinal  portions. 

Symptoms. — The  symptoms  both  of  the  complete  and 
of  the  incomplete  forms  are  usually  sufficiently  obvious  to 
attract  attention  within  the  first  few  days  after  birth. 
When  the  septum  is  perforated,  however,  it  may  be  some 
weeks  or  months  before  the  child  is  brought  for  advice.  I 
have  recently  had  a  case  of  this  kind  under  my  care,  which 
was  satisfactorily  treated  by  prolonged  dilation  with 
rectal  bougies.  The  opening  of  the  bowel  into  the  urinary 
passages  is  productive  of  much  trouble  in  boys,  and  may 
necessitate  the  performance  of  cystotomy  ;  in  girls,  on  the 
other  hand,  the  opening  of  the  rectum  into  the  vagina  is 
of  much  less  serious  import. 

Treatment. — Cases  of  true  imperforate  anus,  marked 


428      THE    SURGICAL    DISEASES    OF    CHILDREN 

by  inability  to  pass  a  motion,  distension  of  the  belly,  and 
vomiting  coming  on  about  the  third  or  fourth  day,  demand 
all  the  energy  and  skill  of  the  surgeon  to  prevent  the 
death  of  the  child.  Effective  surgical  interference  is 
imperatively  called  for  in  these  cases,  yet  the  surgeon 
should  remember  that  a  similar  group  of  symptoms  may 
denote  congenital  strictures,  or  even  complete  absence  of  a 
part  of  the  intestines  other  than  the  rectum,  and  that  in 
some  cases  a  volvulus  may  produce  them.  A  differential 
diagnosis  may  sometimes  be  made,  in  cases  where  the 
stricture  is  beyond  the  reach  of  the  finger,  by  the  gentle 
injection  of  warm  water. 

The  relations  of  the  peritoneum  to  the  bowel  are  of  the 
utmost  importance  in  regard  to  the  operative  measures  to 
be  adopted  for  the  relief  of  this  condition,  for  the  large 
majority  of  cases  have  died  of  peritonitis  after  operation. 
When  the  rectum  is  only  partially  deficient,  the  peritoneum 
is  reflected  from  its  anterior  surface,  and  leaves  the 
posterior  aspect  of  the  bowel  free  to  be  opened.  When 
the  rectum  is  wholly  wanting,  the  intestine  not  passing 
lower  than  the  brim  of  the  pelvis,  Mr.  Curling  says  that 
the  peritoneum  completely  invests  the  terminal  pouch, 
and  must  necessarily  be  wounded  before  the  bowel  can  be 
reached  from  the  perineum.  This  is,  of  course,  of  much 
less  importance  to  us  than  it  was  to  surgeons  who  were 
unable  to  keep  their  wounds  aseptic.  The  danger,  how- 
ever, is  still  sufficiently  real  to  warrant  us  in  laying  down 
the  general  rule,  that  in  no  case  should  an  attempt  be 
made  to  puncture  the  bowel  with  a  trocar  and  canula. 

When  there  is  a  well-formed  anus,  and  the  rectum  is 
only  separated  by  a  thin  septum,  the  membrane  may  be 
divided  with  a  tenotomy  knife,  after  a  catheter  has  been 
passed  along  the  urethra,  the  child  being  ansesthetised, 
and  in  the  lithotomy  position.     If  no  cul-de-sac  be  present, 


DISEASES    OF    THE    RECTUM  429 

an  incision  should  be  carried  from  the  middle  of  the 
perineum  to  the  tip  of  the  coccyx  ;  and  if  the  middle 
line  be  strictly  adhered  to,  there  is  comparatively  little 
bleeding.  The  bulging  bowel  may  be  readily  felt  after  a 
little  careful  dissection  upwards,  taking  care  to  keep  close 
to  the  hollow  of  the  sacrum,  and  remembering  that  the 
bowel  is  usually  situated  within  an  inch  or  an  inch  and  a 
half  of  the  surface.  If  the  bowel  is  found,  it  should  be 
opened  on  its  posterior  aspect,  the  meconium  washed  away, 
and  the  opening  plugged  with  gauze,  the  wound  being 
allowed  to  granulate  without  the  introduction  of  any 
sutures.  The  value  of  this  operation,  as  Mr.  Keetley  has 
shown,  is  enhanced  by  the  fact  that  the  wound  is  easily 
managed,  and  that  it  is  unnecessary  to  take  the  child 
away  from  its  mother.  If  the  bowel  be  not  found,  after 
a  moderate  amount  of  dissection,  the  child  should  be  put 
to  bed  for  twenty-four  hours  to  recover  from  the  shock, 
and  inguinal  colotomy  should  then  be  performed. 

Inguinal  colotomy  in  these  cases  is  preferable  to  Amus- 
sat's  or  to  Callisen's  operation  in  the  loin,  first  because 
there  is  more  room  to  work  in,  and  secondly  because  the 
bowel  is  opened  nearer  to  its  termination,  and  so  there  is 
less  likelihood  of  failing  to  find  it  when,  as  often  happens, 
the  colon  is  displaced  or  presents  other  abnormalities. 
In  addition  to  the  ordinary  arguments  for  the  inguinal 
rather  than  for  the  lumbar  operation,  I  have  before  me 
the  fate  of  Mr.  Baker's  successful  case.  Colotomy  had 
been  performed  in  the  left  lumbar  region  immediately  after 
birth;  the  case  was  successful,  and  is  recorded  in  the  Trans. 
Clin.  Hoc,  vol.  xii.  p.  240.  The  child  died  at  the  age  of 
ten,  having  led  a  miserable  existence.  At  the  post-mortem 
examination  the  whole  intestine  was  found  to  be  greatly 
dilated,  but  below  the  colotomy  wound  it  was  distended 
into  an  enormous  cul-de-sac,  which,  in  the  fresh  condition, 


430      THE    SURGICAL    DISEASES    OF    CHILDREN 

held  a  quart  of  faeces.  At  the  end  of  the  cul-de-sac  was 
a"  small  shrivelled  portion,  representing  the  connective 
tissue  which  intervened  between  the  termination  of  the 
intestine  and  the  anus. 

Mr.  Cripps  recommends  that  when  the  bowel  communi- 
cates with  the  posterior  wall  of  the  vagina,  no  operation 
should  be  performed  until  the  child  is  a  few  months  old. 
It  should  then  be  anaesthetised,  placed  in  the  lithotomy 
position,  and  a  strong  bent  probe  should  be  passed  through 
the  fistulous  opening,  and  made  to  project  towards  the 
perineum  in  the  natural  site  of  the  anus.  If  the  com- 
munication between  the  vagina  and  rectum  be  lateral,  the 
probe  can  be  cut  down  upon  directly  ;  but  if,  as  more  fre- 
quently happens,  the  end  of  the  rectum  communicates  with 
the  vagina,  a  considerable  amount  of  dissection  will  be  re- 
quired before  an  anus  can  be  formed.  Great  care  must  be 
taken  in  the  after-treatment  of  these  cases  to  prevent  the 
wound  closing.  This  is  best  done  by  the  prolonged  use 
of  a  rectal  bougie  of  about  the  size  of  a  No.  18  English 
catheter.  It  is  usually  necessary  to  impress  upon  the 
nurse  or  mother  that  very  serious  damage  may  be  done  to 
the  child  by  using  this  instrument  at  all  roughly. 

It  is  even  more  important  that  an  operation  should  be 
performed  in  atresia  ani  urethralis  than  in  atresia  ani 
vaginalis,  for  Mr.  Page  records  {The  British  Medical 
Journal,  ii.,  1888,  p.  875)  the  case  of  a  man  who,  at  the 
age  of  fifty-four,  was  leading  a  wretched  existence  with 
this  condition.  A  staff  may  be  introduced  into  the  bladder 
in  these  cases,  and  an  accurate  dissection  in  the  middle 
line  towards  the  prostate  should  be  made  until  the  bowel 
is  reached,  the  after-treatment  being  the  same  as  in  the 
previous  variety. 


DISEASES    OF    THE    RECTUM  43 1 

FISTULA  IN  ANO. 

Fistula  in  ano  sometimes  occurs  in  children,  and  is  the 
result  of  an  ischio-rectal  abscess,  often  of  a  tuberculous 
nature,  and  more  rarely  of  spinal  caries  in  the  lumbar 
region.  Two  Italian  children,  members  of  the  same  family, 
were  successively  under  my  care  for  the  treatment  of  this 
affection.  The  sinus  was  laid  open  in  each  case,  and  the 
ordinary  means  of  after-treatment  used  in  adults  were 
adopted  with  slow  but  satisfactory  results.  Ischio-rectal 
abscess  in  children  is  rather  frequently  associated  with 
the  presence  of  foreign  bodies  which  have  passed  through 
the  wall  of  the  bowel.  The  abscess  cavity  should  there- 
fore be  explored  with  a  probe  after  it  has  been  laid  open. 

FISSURE  OF  THE  ANUS. 
Fissure  of  the  anus  is  occasionally  met  with  in  children 
It  causes  a  sharp  pain  at  the  time  the  motion  is  passed, 
followed  by  a  rhythmical  and  dull  pain,  lasting  for  some 
considerable  time  after  defecation.  A  local  application  of 
some  ointment  containing  cocain  is  serviceable  in  the 
slighter  cases,  supplemented  with  one-drachm  doses  of 
hazeline,  pulv.  glycyrrhizae  co.,  or  confection  of  senna,  to 
prevent  the  passage  of  hard  faeces.  The  ointment  I 
usually  order  consists  of : — 

R.     Hydrarg.  subchlor.,  grs.  iv. 

Cocain.  hydrochlor.,  grs.  iv. 

Ext.  belladonnse,  grs.  ii. 

Ungt.  sambuci,  ounce  i. 
M.  Ft.  Ungt. 
Sig.     To  be  used  frequently. 

In  the  more  severe  cases,  and  when  the  ointment  fails  to 
relieve  the  pain,  the  child  should  be  anaesthetised,  and  an 
incision  made  through  the  base  of  the  ulcer  in  the  manner 
usually  followed  in  adults. 


CHAPTER  XXI 
DISEASES  AND  INJURIES  OF  THE  KIDNEY49 

HYDRONEPHROSIS. 

Symptoms. — Hydronephrosis,  or  distension  of  the  kidney 
by  urine,  is  either  congenital  or  acquired.  It  is  charac- 
terised by  a  tumour  of  definite  shape,  sometimes  smooth 
and  sometimes  irregular  in  outline.  The  tumour  is  situ- 
ated in  the  flank  and  does  not  usually  extend  beyond  the 
middle  line  of  the  abdomen.  It  is  a  tense  swelling,  and 
a  sense  of  fluctuation  is  usually  attainable.  It  is  dull  on 
percussion,  except  where  it  is  crossed  by  intestine.  It 
is  likely  to  be  mistaken  for  an  ovarian,  mesenteric,  or 
hydatid  cyst. 

Congenital  Hydronephrosis. 
^Etiology. — Congenital  hydronephrosis  is  the  result  of 
local  malformations  or  irregular  origins  of  the  ureters 
leading  to  kinks  or  constrictions  in  some  part  of  their 
course,  or  it  may  result  from  similar  alterations  in  the 
urethral  passage.  In  a  few  cases  it  is  the  result  of  valvu- 
lar prolongations  of  the  mucous  membrane  of  the  ureters 
or  of  the  urethra.  I  saw  it  in  one  case  associated  with  an 
imperforate  rectum,  in  which  the  sigmoid  flexure,  distended 
with  fasces  and  abnormally  situated,  lay  over  the  ureters 
in  such  a  manner  as  to  prevent  the  urine  flowing  freely 
along    them.      There    are   therefore    several    varieties   of 

432 


DISEASES    AND    INJURIES    OF    THE    KIDNEY     433 

congenital  hydronephrosis,  for  it  may  be  either  unilateral, 
bilateral,  permanent,  or  intermittent ;  the  intermittent 
forms  being  those  in  which  the  urine  only  escapes  along 
its  ureter,  when  it  has  been  pent  up  until  the  pressure  is 
sufficient  to  enable  it  to  overcome  the  obstruction.  The 
permanent  forms  of  hydronephrosis  may  show  themselves 
at  birth,  or  only  after  the  lapse  of  many  years. 

Pathology. — The  method  by  which  hydronephrosis  is 
produced  has  lately  been  the  subject  of  a  careful  experi- 
mental study  by  Dr.  Byron  Robinson,49  of  Chicago.  He 
shows  that  complete  occlusion  of  the  ureter  produces 
atrophy  of  the  kidney  in  a  few  months,  whilst  its  partial 
occlusion  produces  a  condition  of  hydronephrosis.  The 
kidney  will  bear  complete  occlusion  for  some  weeks,  and 
will  still  resume  its  function  as  soon  as  the  obstruction 
and  the  pressure  are  removed. 

Treatment. — The  treatment  consists  in  aspirating  or 
puncturing  the  tumour,  and  in  cases  of  long  standing  a 
thick  and  brownish  fluid  is  generally  withdrawn.  The 
needle  is  entered  half-way  between  the  last  rib  and  the 
crest  of  the  ilium,  about  three  inches  from  the  vertebral 
spine,  and  its  point  should  be  directed  somewhat  forwards. 
The  tumour  may  be  cut  down  upon  and  drained,  if  it  re- 
fills ;  and  if  this  fails  to  cure,  or  if  its  contents  become 
septic,  a  nephrectomy  should  be  performed.  In  skilled 
hands,  and  with  due  precautions,  children  bear  the  removal 
of  a  kidney  excellently.  Care  must  be  taken,  however, 
that  the  opposite  kidney  is  healthy,  and  the  abdominal 
incision  is  pref erred  by  some  surgeons  to  the  ordinary 
lumbar  operation. 

Traumatic  Hydronephrosis. 

etiology.— Traumatic  hydronephrosis  is  a,  convenient 
term,  though  it  is  not  scientifically  correct  in  the  majority 

F  F 


434      THE    SURGICAL    DISEASES    OF    CHILDREN 

of  cases.  Monod  has  shown  that  the  term  is  used  to  in- 
clude two  distinct  conditions :  true  hydronephrosis,  in 
which  the  pelvis  of  the  kidney  is  dilated,  owing  to  injuries 
to  the  ureter  leading  to  its  rupture ;  to  extravasation  about 
the  ureter ;  or  to  a  clot  in  the  ureter.  These  cases  are 
rare,  and  the  swelling  only  appears  after  a  long  interval. 
In  a  few  still  rarer  cases  the  injury  may  give  rise  to 
a  movable  kidney,  and  this  may  be  followed  by  hydro- 
nephrosis. The  second  group  is  that  in  which  a  tumour 
appears  within  a  few  weeks  of  the  injury  without  pain  or 
constitutional  symptoms.  The  kidney  remains  nearly 
normal  in  these  cases,  but  the  accident  has  caused  some 
separation  of  the  perinephric  tissue,  and  the  urine  finding 
its  way  drop  by  drop  through  a  rent  in  the  pelvis  or  in 
the  ureter,  collects  in  the  space  thus  formed,  and  slowly 
enlarges  it  into  a  tumour,  whose  walls  consist  of  the  con- 
densed retro-peritoneal  connective  tissue. 

Symptoms. — The  symptoms  of  such  a  case  are  a 
temporary  hematuria  following  an  injury  to  the  region  of 
the  kidney.  There  is  a  little  tenderness  over  the  abdomen, 
but  there  is  a  marked  absence  of  shock,  and  the  tempera- 
ture may  hardly  be  raised  above  the  normal.  The  child 
appears  to  be  quite  well  after  a  few  days'  rest.  The 
abdominal  muscles,  however,  soon  become  tense,  and  within 
a  fortnight  to  six  weeks  of  the  injury  a  fluctuating  tumour 
with  a  well-defined  margin  is  discovered  in  the  belly. 
The  tumour  is  usually  painless,  but  its  formation  may  be 
attended  with  pain  and  restlessness.  Puncture  of  this 
swelling  shows  that  it  contains  a  clear  urinous  fluid,  in 
which  is  albumin  and  urea. 

Treatment.  —  The  tumour  has  disappeared  spon- 
taneously in  a  few  cases ;  in  many  it  has  not  reappeared 
after  one  or  more  tappings  ;  whilst  in  others  it  has  been 
cured  by  free  incision  and  drainage.     It  has  often  been 


DISEASES    AND    INJURIES    OF    THE    KIDNEY-   435 

necessary  to  remove  the  kidney,  though  in  cases  of 
traumatic  hydronephrosis  it  is  better  not  to  adopt  this 
method  until  all  others  have  been  tried,  for  the  kidney 
may  remain  healthy. 

Dr.  Aldibert  has  recently  collected  the  varkms  cases  on 
record,  and  he  finds  that  there  are  seventeen  ;  of  which  one 
disappeared  spontaneously ;  seven  were  treated  by  punc- 
ture, and  of  these  six  were  cured  and  one  died  ;  nine  were 
drained  with  or  without  a  secondary  nephrectomy,  and  of 
these  two  died  and  seven  were  cured.  In  cases  of  true 
traumatic  hydronephrosis,  it  is  well  to  ascertain  the  con- 
dition of  the  ureter  before  proceeding  to  extirpate  the 
kidney,  as  an  abdominal  tumour  in  some  respects  simu- 
lating hydronephrosis  is  occasionally  produced  by  dilata- 
tion of  the  ureters. 

WOUNDS  OF  THE  KIDNEY. 

Wounds  of  the  kidney  are  of  much  less  frequent  oc- 
currence than  ruptures.  They  are  usually  associated  with 
intra-peritoneal  haemorrhage,  and  may  require  the  removal 
of  the  kidney  through  an  anterior  incision. 

RUPTURE    OF   THE   KIDNEY. 

etiology. — Rupture  of  the  kidney  is  by  no  means  an 
uncommon  accident  in  children,  owing  to  the  frequency 
with  which  they  are  run  over  by  vans  in  the  streets  of  a 
large  town  ;  but  the  liver  is  more  often  lacerated  than  the 
kidney. 

Symptoms. — Examination  of  a  child  whose  kidney  has 
been  ruptured  by  direct  violence  will  generally  reveal  a 
bruise  or  other  mark  of  injury  on  the  abdomen  or  flank, 
and  there  is  a  local  tenderness.  The  urine  may  or  may 
not  contain  blood,  and  there  is  usually  much  less  shock 
than  after  injury  to  the  other  viscera.     The  bleeding  is 


43^      THE    SURGICAL    DISEASES    OF    CHILDREN 

often  intra-peritoneal,  due  partly  to  the  fact  that  a  child 
has  very  little  fat  round  its  kidney,  and  partly  owing  to 
the  elasticity  of  the  walls  allowing  the  organ  to  be  pushed 
forwards  until  the  peritoneum  is  ruptured.  Death  rapidly 
ensues  if  the  injury  has  been  severe,  or  the  laceration 
extensive. 

Prognosis.  —  Repair  very  often  takes  place  in  the 
slighter  cases  of  injury,  and  the  child  only  requires  to  be 
kept  at  rest  in  bed.  Recovery  takes  place  so  rapidly  that 
the  accuracy  of  the  diagnosis  might  be  called  in  question 
did  not  the  pathologist  know  how  completely  the  surround- 
ing tissues  become  adherent  to  the  injured  part  of  the 
kidney.  In  less  favourable  cases  hydronephrosis,  pyo- 
nephrosis, or  perinephric  abscess  may  be  the  result,  and 
will  require  appropriate  treatment. 

Differential  Diagnosis.— The  differential  diagnosis  of 
ruptured  kidney  has  to  be  made  from  similar  injuries  of 
the  intestines,  spleen,  liver,  and  bladder.  The  regular 
action  of  the  bowels,  the  continuance  of  a  normal  or  only 
slightly  raised  temperature,  the  comparative  absence  of 
shock,  repeated  micturition,  and  the  passage  of  urine 
which  does  not  contain  blood  in  excessive  quantity,  would 
be  signs  pointing  to  rupture  of  the  kidney  alone  in  doubt- 
ful cases  of  abdominal  injury. 

Treatment.— Absolute  rest  in  bed  is  of  service  in  the 
treatment  of  slight  ruptures  of  the  kidney.  In  the  most 
severe  forms  all  the  symptoms  of  intra-peritoneal  haemor- 
rhage will  appear,  and  the  sole  chance  of  saving  the  child's 
life  will  lie  in  performing  a  laparotomy  and  removing  the 
kidney.  Death  will  ensue  in  many  cases  before  this  can 
be  done,  or  the  surgeon  may  not  feel  himself  justified  in 
undertaking  it  ;  for  he  may  find  it  impossible  to  make  an 
accurate  diagnosis,  so  closely  do  the  symptoms  of  shock 
simulate  those  of  haemorrhage  into  the  peritoneal  cavity. 


DISEASES    AND    INJURIES    OF    THE    KIDNEY      437 

RUPTURE   OF  THE  URETERS. 

The  ureters  are  ruptured  by  direct  violence.  They  are 
blocked  and  inflamed  by  the  impaction  of  calculi.  They 
are  sometimes  subject  to  tuberculous  inflammation.  They 
come,  therefore,  in  various  ways  under  the  surgeon's 
cognisance. 

Diagnosis.— The  dilated  and  inflamed  ureter  can  be  felt, 
as  an  oblong  tumour  passing  over  the  brim  of  the  pelvis, 
by  deep  pressure  at  the  point  of  intersection  of  a  horizontal 
line  joining  the  anterior  superior  spines  of  the  ilium,  and  a 
vertical  line  passing  through  the  pubic  spine.  The  vesical 
portion  can  be  felt  in  man  by  a  rectal  examination,  and 
Guyon  has  called  attention  to  the  exquisite  sensitiveness 
of  this  part  of  the  ureter  even  when  a  calculus  is  impacted 
in  the  tube  at  a  much  higher  point. 

Symptoms. — The  symptoms  of  impacted  calculus  are 
well  known ;  those  accompanying  a  ruptured  ureter  are 
much  more  obscure.  Mr.  Page  records  the  case  of  a  boy, 
aged  five,  who  was  run  over  by  a  light  vehicle.  There  was 
no  evidence  of  serious  injury,  so  the  patient  was  sent  home. 
Two  days  later,  however,  his  parents  brought  him  to  the 
hospital,  having  noticed  blood  in  his  urine.  The  child 
complained  of  pain  in  his  right  iliac  fossa.  He  remained 
well  until  about  twenty  days  after  the  accident,  when  his 
condition  became  worse,  and  it  was  resolved  to  operate. 
The  abdomen  was  opened,  and  a  large  fluctuating  swelling, 
about  the  size  of  a  Jaffa  orange,  was  discovered  in  the 
right  loin.  It  was  opened  and  emptied.  The  kidney  was 
healthy,  and  it  was  not  thought  advisable  to  make  a  pro- 
longed search  for  a  possible  rupture  in  the  ureter.  Four 
days  after  the  operation  the  dressings  were  found  to  be 
saturated  with  fluid  of  a  urinous  odour.  The  temperature 
of  the  patient  rose,  and  there  were  other  evidences  of  septic 


43§      THE    SURGICAL    DISEASES    OF    CHILDREN 

infection.  A  secondary  nephrotomy  was  therefore  per- 
formed. The  child  immediately  began  to  improve,  and 
eventually  made  an  excellent  recovery. 

Treatment. — This  case  exemplifies  the  difficulty  at- 
tending the  treatment  of  accumulations  of  urine  due  to 
injuries  of  the  ureter.  They  are  very  prone  to  become 
septic  if  they  are  aspirated,  and  the  best  treatment  is  to 
expose  them  freely.  This  may  be  done  either  by  a  median 
or  by  a  lateral  incision  through  the  abdominal  walls.  The 
upper  two-thirds  of  the  ureter  can  be  explored  by  a  con- 
tinuation of  the  lumbar  nephrotomy  incision  from  the 
twelfth  rib  carried  obliquely  downwards  across  the  flank 
one  inch  anterior  to  the  ilium,  and  then  to  the  centre  of 
Poupart's  ligament.  The  sac  should  then  be  opened  and 
drained.  The  opening  of  the  ureter  into  the  sac  is  found 
by  incising  the  ureter  below  the  sac,  and  passing  a  probe 
upwards  into  it.  The  valve  on  the  inner  wall  of  the  ureter 
should  then  be  divided  longitudinally,  and  means  should 
be  taken  to  prevent  the  recurrence  of  such  a  condition  by 
drawing  the  corners  of  the  longitudinal  incision  together 
with  a  suture  to  transform  the  longitudinal  into  a  trans- 
verse incision,  as  is  recommended  by  Christian  Fenger  in 
his  interesting  article  upon  "The  Surgery  of  the  Ureter,"  50 
in  The  Annals  of  Surgery  for  September,  1894,  p.  257. 

PYONEPHROSIS  AND  PERINEPHRIC  ABSCESS. 

etiology. — Pyonephrosis,  or  the  condition  in  which 
the  kidney  is' dilated  and  contains  pus,  arises  from  a  variety 
of  causes.  It  is  very  often  connected  with  the  presence  of 
renal  calculi.  It  occurs  in  tuberculous  kidneys,  and  it  may 
be  secondary  to  a  hydronephrosis.  The  term  pyonephrosis 
is  also  used  loosely  by  some  surgeons  to  denote  a  peri- 
nephric abscess  resulting  from  the  puncture  of  a  traumatic 


DISEASES    AND    INJURIES    OF    THE    KIDNEY     439 

hydronephrosis,  although,  as  has  been  said,  such  collections 
are  produced  by  leakage  into  the  tissues  round  the  kidney 
or  injured  ureter,  and  never  lead  to  distension  of  the 
kidney  itself. 

Symptoms. — The  symptoms  of  pyonephrosis  are  usually 
similar  to  those  of  a  hydronephrosis,  except  that  the 
temperature  of  the  patient  may  indicate  by  its  daily  oscil- 
lations the  presence  of  pus.  Here,  as  in  the  other  suppu- 
rative diseases  in  children,  the  thermometer  is  not  always 
a  trustworthy  guide,  for  there  may  be  a  large  collection  of 
pus  and  yet  no  increase  in  the  temperature.  Much  pain" 
radiating  downwards  may  be  felt  from  the  tumour  pressing 
upon  the  lumbar  plexus,  and  the  patient  often  keeps  his 
thigh  slightly  bent,  and  leans  towards  the  affected  side  as 
though  his  spine  or  hip  were  the  seat  of  disease.  Puncture 
of  the  tumour  will  alone  make  the  diagnosis  certain  in 
these  obscure  cases. 

Treatment. — The  treatment  of  traumatic  pyonephrosis 
consists  in  laying  the  abscess  cavity  freely  open  by  an 
incision  carried  through  the  flank.  The  pus  should  be 
thoroughly  washed  away  and  the  cavity  explored.  The 
kidney  should  be  removed  if  it  is  found  to  be  disorganised. 
If  the  pus  has  been  formed  in  the  connective  tissue  around 
the  kidney,  nephrectomy  should  not  be  performed,  but  the 
walls  of  the  abscess  should  be  scraped  and  its  cavity 
should  be  well  flushed  and  dried.  The  wound  may  then 
be  closed  without  draining  it,  and  an  endeavour  may  be 
made  to  get  union  by  first  intention  ;  but  if  the  surgeon 
thinks  that  this  is  impossible,  he  should  drain  the  cavity. 
Complete  recovery  often  takes  place,  but  in  some  cases  a 
sinus  remains.  A  secondary  nephrectomy  is  sometimes 
required  before  this  sinus  will  heal,  and  the  operation 
is  indicated  when  it  discharges  pus  mingled  with  urine. 
The  secondary  operation,  however,  is  much  more  difficult 


440      THE    SURGICAL    DISEASES    OF    CHILDREN 

than  primary  nephrectomy,  for  the  kidney  is  small  and  the 
surrounding  parts  consist  of  dense  fibrous  tissue. 

TUBERCULOUS  NEPHRITIS. 51 

Pathology. — Tuberculous  inflammation  of  the  kidney  is 
by  no  means  rare  in  children.  It  occurs  in  the  form  of 
miliary  tubercle  affecting  the  pelvis  alone,  or  as  a  tuber- 
culous pyelo-nephritis  in  which  the  whole  kidney  becomes 
a  mass  of  caseating  material,  separated  into  lobules  by  the 
fibrous  framework  of  the  organ.  The  surgeon  is  only  in- 
terested in  cases  of  tuberculous  pyonephrosis.  It  appears 
to  be  primary  in  children,  for  even  when  the  symptoms 
have  lasted  for  long  periods  of  time  it  may  be  impossible 
to  discover  other  tuberculous  lesions ;  and  although  the 
infected  urine  has  traversed  the  ureters  and  bladder  for 
many  months,  they  are  often  found  to  be  perfectly  healthy. 
The  renal  disease  may,  on  the  other  hand,  be  only  a  part  of 
a  general  tuberculosis. 

Symptoms. — The  symptoms  may  very  closely  resemble 
those  produced  by  renal  calculus.  Frequency  of  mic- 
turition, with  pain  on  passing  water,  is  an  early  and  very 
troublesome  sign,  and  it  often  persists  in  spite  of  all  local 
and  general  treatment.  The  urine  contains  pus,  phos- 
phates, and  sometimes  blood.  It  usually  smells  offensively. 
There  may  be  attacks  of  renal  colic  from  time  to  time,  with 
local  pain  and  tenderness  in  the  loin.  Careful  examination 
of  the  flank  with  the  patient  lying  upon  the  healthy  side 
may  lead  to  the  detection  of  a  tumour  in  the  situation  of 
the  kidney,  whilst  percixssion  shows  that  the  area  of  renal 
dulness  is  considerably  increased.  There  is  often  a  hectic 
temperature  which  may  serve  to  distinguish  the  condition 
from  a  calculus  formed  in  a  healthy  kidney,  though  it  is 
not  by  any  means  a  trustworthy  guide. 


DISEASES    AND    INJURIES    OF    THE    KIDNEY     44 1 

Diagnosis. — The  tumour  iu  the  loin  is  liable  to  be 
mistaken  for  an  enlarged  spleen,  or  for  an  hepatic  cyst, 
according  as  it  lies  upon  the  left  or  upon  the  right  side. 
It  may  be  distinguished  from  an  enlargement  of  the  spleen, 
by  noticing  that  the  spleen  does  not  extend  so  far  down- 
wards into  the  iliac  fossa  as  the  kidney  ;  by  remembering 
that  the  spleen  has  a  sharp  edge  which  can  usually  be 
felt,  and  by  percussing  the  abdomen  ;  for  the  spleen  has  no 
colon  in  front  of  it,  whilst  a  part,  at  any  rate,  of  a  renal 
tumour  is  resonant  where  the  colon  crosses  it.  Careful 
percussion  on  the  right  side  will  show  that  there  is  an 
interval  between  the  upper  border  of  a  renal  tumour  and 
the  lower  border  of  the  liver. 

Prognosis. — The  prognosis  is  always  grave  in  cases  of 
tuberculous  pyelo-nephritis,  for  both  kidneys  are  frequently 
diseased. 

Treatment. — Nephrectomy  is  advisable  when  the  stir 
geon  can  satisfy  himself  that  only  one  kidney  is  affected, 
and  the  operation  should  be  done  at  once  through  a  lumbar 
incision.  The  tumour  may  be  incised  and  drained,  when 
there  is  doubt  as  to  the  condition  of  the  opposite  organ, 
leaving  a  nephrectomy  to  be  performed  at  a  later  stage,  if 
it  is  found  to  be  desirable.  Children  bear  extirpation  of 
the  kidney  for  inflammatory  disease  so  well,  that  out  of 
thirteen  cases  of  primary  nephrectomy  for  tuberculous 
nephritis  collected  by  Aldibert,49  nine  patients  were  cured. 

RENAL  CALCULUS. 

Stone  in  the  kidney  is  not  a  frequent  cause  of  trouble  in 
children,  though  it  is  not  of  rare  occurrence,  partly  because 
the  kidneys  of  children  appear  to  tolerate  the  presence  even 
of  large  calculi,  especially  if  they  are  embedded  in  the 
cortex,  and  partly  because  the  majority  of  renal  calculi  in 


442      THE    SURGICAL    DISEASES    OF    CHILDREN 

children  are  very  small,  and  are  soon  passed  on  into  the 
bladder. 

Symptoms. — The  symptoms  of  renal  calculus  in  chil- 
dren are  practically  the  same  as  in  adults.  There  is  localised 
pain  felt  in  the  loin,  and  liable  to  exacerbations  radiating 
to  the  penis  and  causing  retraction  of  the  testicle  in  boys, 
or  felt  at  the  umbilicus.  The  pain  is  increased  by  abrupt 
movements  and  is  relieved  by  rest.  It  can  often  be  elicited 
by  percussing  the  loin  sharply  just  beneath  the  tips  of  the 
last  two  ribs,  the  blow  being  directed  upwards,  forwards, 
and  slightly  inwards,  when  the  patient  is  standing  up- 
right in  front  of  the  surgeon,  who  kneels  before  him.  This 
direct  evidence  of  the  existence  of  a  renal  calculus  is  some- 
times important,  for  the  pain  is  occasionally  referred  to  the 
kidney  which  does  not  contain  the  stone,  whilst  in  other 
cases  it  is  felt  in  the  bladder.  Such  errors  are  more 
common  in  children  than  in  adults,  for  children  often  have 
great  difficulty  in  localising  their  sensations.  The  error 
in  localisation  is  physiological  rather  than  physical,  how- 
ever; for  when  the  pain  of  a  renal  calculus  is  felt  in  the 
bladder,  it  is  accompanied  by  painful  micturition  and  a 
false  incontinence  of  urine.  Hematuria  is  a  very  constant 
symptom  of  renal  calculus  in  children,  and  it  is  sometimes 
sufficient  to  lead  to  extreme  anaemia — a  condition  which  is 
readily  explained  by  remembering  how  badly  children  bear 
losses  of  blood,  and  how  long  they  are  in  recovering  from 
a  serious  haemorrhage. 

The  urine  may  remain  clear  and  acid ;  it  may  be  wholly 
devoid  of  sediment,  even  where  the  patient  has  repeated 
attacks  of  renal  colic,  but  there  is  usually  a  little  albumin. 
Microscopic  examination  of  the  urinary  deposit  in  such 
cases  will  sometimes  reveal  the  presence  of  numerous  crys- 
tals of  oxalate  of  lime,  and  will  thus  clear  up  the  diagnosis 
of  an  obscure  case.     In  many  cases,  however,  the  urine 


DISEASES    AND    INJURIES    OF    THE    KIDNEY     443 

contains  pus,  it  is  alkaline,  there  are  abundance  of  phos- 
phates, and  it  stinks. 

Diagnosis. — It  is  often  very  difficult  to  distinguish 
such  cases  of  pyonephrosis  due  to  calculus  from  those 
caused  by  tubercle,  except  by  the  results  of  inoculation 
upon  guinea-pigs,  for  the  bacteriological  evidence  is  not 
yet  sufficiently  reliable. 

The  differential  diagnosis  lies  between  tubercle  and 
calculus,  and  between  spinal  disease  and  calculus.  Severe 
attacks  of  renal  colic,  with  the  presence  of  much  blood  in 
the  urine  and  a  comparatively  small  amount  of  pus,  would 
point  to  a  stone  in  the  kidney  rather  than  to  tuberculous 
disease.  The  absence  of  blood  or  pus  in  the.  urine,  when 
repeated  examinations  have  been  made  at  sufficiently  long 
intervals,  would  point  rather  to  caries  of  the  spine  than  to 
renal  calculus,  especially  if  the  disease  has  lasted  less  than 
a  year,  and  the  symptoms  have  shown  themselves  in  a 
tuberculous  patient.  On  the  other  hand,  if  the  trouble 
is  of  several  years'  duration,  if  the  symptoms  have  been 
intermittent,  and  if  there  has  been  hematuria,  there  is 
presumptive  evidence  of  a  renal  calculus.  Careful  mani- 
pulation by  skilled  hands  will  often  detect  very  slight 
alterations  in  the  shape,  size,  and  condition  of  the  kidney, 
especially  if  the  patient  be  placed  upon  his  sound  side 
and  be  made  to  breathe  deeply  whilst  his  loin  is  being 
examined. 

Treatment. — The  treatment  of  renal  calculus  and  of 
calculous  pyelitis  is  still  a  matter  of  discussion,  although 
all  surgeons  are  agreed  that  operative  interference  is 
desirable  when  the  pain  is  so  great  as  to  render  the  patient 
a  chronic  invalid.  When  the  diagnosis  has  been  made, 
it  has  to  be  determined  whether  one  or  both  kidneys  are 
affected,  and  then  whether  the  affected  organ  is  healthy 
so  that  the  stone  may  be  removed  from  it,  or  whether  it  is 


444      THE    SURGICAL    DISEASES    OF    CHILDREN 

so  disorganised  that  it  is  necessary  to  remove  kidney  and 
stone  together.  When  nephrolithotomy  has  been  decided 
upon,  there  still  remains  the  last  difficulty  of  finding  the 
stone ;  for  when  the  calculus  is  small  and  lies  in  the  upper 
part  of  the  cortex,  I  have  seen  the  most  experienced  sur- 
geons fail  in  their  endeavours  to  find  it.  Lumbar  nephro- 
lithotomy is  usually  sufficient ;  but  when  the  kidney  is 
very  large,  and  when  it  is  doubtful  which  organ  is  affected, 
or  whether  both  contain  calculi,  an  anterior  abdominal 
incision  gives  the  best  results.  A  large  suppurating  kid- 
ney should  first  be  drained  through  a  lumbar  incision,  the 
calculi  being  removed  if  possible.  It  may  afterwards  be 
removed  at  the  leisure  of  the  surgeon  and  the  desire  of  the 
patient. 

MOVABLE  AND  FLOATING  KIDNEYS. 

Movable  and  floating  kidneys  occur  in  children,  but 
much  less  frequently  than  in  adults.  Such  kidneys  may 
become  diseased,  but  they  do  not  appear  to  be  more 
liable  than  kidneys  anchored  in  the  ordinary  manner- 
Mr.  Warrington  Haward  has  reported  a  case  in  which  a 
tuberculous  movable  kidney  was  excised.  The  patient 
was  a  girl,  aged  16,  who  had  suffered  from  increased  fre- 
quency of  micturition  for  sixteen  months.  The  operation 
was  performed  through  an  anterior  abdominal  incision,  and 
the  patient  died  forty-four  hours  later. 

RENAL  TUMOURS. 

Pathology.— The  tumours  of  the  kidney  are  innocent 
and  malignant. 

Innocent  Tumours. 

The  innocent  tumours  are  fibromata,  adenomata,  and 
cystic.     They  are  sometimes  intimately  blended  with  the 


DISEASES    AND    INJURIES    OF    THE    KIDNEY     445 

kidney  substance,  and  are  sometimes  isolated  from  it. 
They  are  much  less  common  than  the  sarcomata,  which 
form  the  large  majority  of  renal  tumours  in  children.  The 
serous  cysts  found  in  connection  with  the  innocent  as  well 
as  the  malignant  tumours  of  the  kidney  are  probably  in 
all  cases  retention  cysts,  and  have  their  origin  in  these 
remains  of  the  Wolffian  body  which  form  the  posterior 
part  of  the  primitive  mesonephros.  Dermoids  in  their 
various  forms  are  occasionally  found. 

Diagnosis. — The  innocent  tumours  of  the  kidney  are 
not,  as  a  rule,  capable  of  diagnosis  unless  they  attain  to  a 
very  large  size.  They  give  rise  to  few  symptoms  except 
slight  hematuria,  and  they  are  not  therefore  of  practical 
interest  to  the  surgeon. 

Malignant  Tumours.52 

Pathology. — Malignant  tumours  of  the  kidney  in  chil- 
dren are  nearly  always  sarcomata,  and  they  are  generally 
atypical,  for  it  is  only  in  rare  cases  that  they  can  be  said 
to  be  of  the  round,  spindle,  or  other  variety  of  sarcoma. 
They  must  therefore  very  often  be  classed  as  teratomata, 
and  amongst  these  the  rhabdomyosarcomata  or  malignant 
tumours  containing  striped  muscle  fibres  are  by  no  means 
uncommon ;  whilst  in  other  cases  they  may  present  a 
cystic  and  adenomatous  type,  apparently  innocent,  but 
often  running  a  malignant  course,  for  they  may  recur, 
and  they  sometimes  disseminate.  The  cystic  growth  may 
form  an  integral  portion  of  the  kidney,  but  it  is  usually 
separated  from  the  glandular  substance  by  a  more  or  less 
well-marked  capsule.  The  cysts  are  lined  with  cubical 
epithelium. 

Malignant  tumours  grow  rapidly,  anil  they  are  often 
so  soft  as  to  be  mistaken  for  chronic  abscesses,  for  they 
give  the  sense  of  fluctuation.     Tho  tumours  have  usually 


446      THE    SURGICAL    DISEASES    OF    CHILDREN 

attained  to  a  considerable  size  before  they  cause  pain  or 
hematuria,  and  it  is  then  too  late  to  remove  them,  for  they 
disseminate  rapidly,  and  the  lumbar  glands  are  early 
affected. 

Treatment. — Many  nephrectomies  have  been  performed 
by  different  surgeons  in  the  hope  of  removing  them ;  but 
50  per  cent,  of  the  operations  have  proved  fatal,  and 
recurrence  has  taken  place  in  nearly  all  the  rest.  The 
operation  is  performed  through  an  anterior  incision  after 
the  patient  has  been  placed  in  Trendelenburg's  position 
(p.  391),  as  this  diminishes  the  venous  haemorrhage  and 
improves  the  heart's  action.  The  tumour  should  be 
shelled  out  of  its  capsule  if  possible,  and  its  pedicle 
should  be  carefully  ligatured.  Dr.  Robert  Abbe  52  has  re- 
cently reported  two  cases  in  which  a  sarcoma  of  the  kidney 
was  removed  from  a  child,  and  in  each  case  the  patient 
was  in  good  health  a  year  afterwards.  He  took  special 
care  to  prevent  loss  of  blood  at  the  time  of  the  operation, 
and  he  kept  the  patient  at  an  angle  of  30°  during,  and  for 
two  days  after,  the  nephrectomy.  The  child  was  kept  very 
warm,  and  in  addition  to  the  ordinary  means  of  preventing 
shock,  enemata  of  two  ounces  of  hot  black  coffee  were 
administered. 

Secondary  sarcomata  occur  tolerably  frequently  in  chil- 
dren, and  an  interesting  variety  once  came  under  my 
observation  in  a  boy  of  ten  years  old.  He  had  multiple 
tumours  of  the  orbits,  internal  ear,  cerebrum,  dura  mater, 
kidneys,  and  other  organs,  which  appeared  to  have  been 
growing  for  about  six  months.  They  were  sarcomatous  in 
character  and  were  of  a  bright  green  colour  (p.  150). 


CHAPTER  XXII 
DISEASES   OF   THE   BLADDER 

VESICAL  CALCULI.53 

Stoxe  is  so  common  in  children  that,  taking  all  the  cases 
of  vesical  calculi,  it  has  been  estimated  that  50  per  cent, 
of  the  patients  affected  are  under  the  age  of  puberty.  The 
calculi  are  usually  single  and  renal  in  origin,  though  in 
exceptional  cases  they  may  be  formed  around  pieces  of 
dead  bone  which  have  gained  access  to  the  bladder  along 
fistulse  connecting  it  with  the  acetabulum,  or  with  the 
spine. 

Symptoms. — The  symptoms  are  usually  more  acute  in 
children  than  in  adults,  for  in  children  the  bladder  is  very 
sensitive.  The  desire  to  pass  water  is  frequent  and 
urgent.  The  child  is  listless  and  does  not  play  in  the 
simpler  cases,  whilst  in  the  more  severe  there  is  pain 
either  at  the  beginning  or  at  the  end  of  the  act.  The 
pain  may  continue  for  ten  or  fifteen  minutes  after  mic- 
turition. It  is  referred  to  the  lower  part  of  the  abdomen 
and  to  the  end  of  the  penis.  It  is  somewhat  relieved  by 
pulling  upon  the  foreskin,  so  that  the  prepuce  is  often 
found  to  be  elongated  and  either  sore  or  thickened.  It 
can  sometimes  be  relieved  when  it  occurs  at  the  beginning 
of  micturition  by  inverting  the  child  ;  but  the  unhappy 
patient  usually  learns  for  himself,  and  adopts  instinctively 
the  position  in  which  he  can  pass  his  water  with  the  least 
discomfort.  The  pain  is  often  very  severe,  for  it  gives  a 
worn  appearance  to  the  child,  somewhat  similar  to  that 

447 


448      THE    SURGICAL    DISEASES    OF    CHILDREN 

seen  in  cases  of  spinal  caries.  The  urine  is  often  passed 
in  small  quantities  at  a  time  and  its  flow  may  be  inter- 
rupted, for  the  prostate  is  so  rudimentary  that  the  stone 
may  fall  over  the  vesical  orifice  of  the  urethra.  It  is  for 
this  reason  that  vesical  calculi  in  children  occasionally 
become  impacted  in  the  urethra.  The  presence  or  absence 
of  hsematuria,  with  or  without  mucus  and  pus,  will  depend 
upon  the  nature  of  the  stone  ;  and  as  mulberry  calculi  are 
tolerably  common,  bleeding  is  not  of  rare  occurrence.  An 
inguinal  hernia  or  a  prolapse  of  the  rectum  may  be  the 
result  of  the  constant  straining  associated  with  the  pre- 
sence of  a  stone  in  the  bladder. 

Diagnosis.  —  The  symptoms  produced  by  a  vesical 
calculus  have  to  be  distinguished  from  those  produced  by 
phimosis,  by  congenital  narrowing  of  the  meatus,  by  foreign 
bodies  impacted  in  the  urethra,  by  cystitis,  and  by  tumours 
of  the  bladder.  A  small  stone  is  readily  overlooked,  but  it 
may  often  be  discovered  by  adopting  the  plan  recommended 
by  Surgeon-Major  Freyer.  He  introduces  an  evacuating 
catheter  into  the  bladder,  and  applies  to  its  end  the 
aspirator  filled  with  a  solution  of  boric  acid  at  100°  F. 
Alternate  compression  and  relaxation  of  the  aspirator  will 
very  soon  bring  even  a  minute  stone  against  the  eye  of 
the  evacuating  catheter,  with  sufficient  force  to  render  its 
presence  in  the  bladder  quite  certain. 

The  presence  of  a  stone  of  moderate  or  of  large  size  is 
usually  determined  without  difficulty  by  sounding.  The 
sound  should  be  very  blunt  and  very  short  in  the  beak,  and 
it  should  be  kept  along  the  upper  wall  of  the  urethra 
whilst  it  is  being  passed.  A  bimanual  examination  with 
one  finger  in  the  rectum  may  always  be  adopted  with 
advantage  in  these  cases,  as  owing  to  the  small  size  of 
the  prostate,  the  bladder  wall  is  in  close  contact  with  the 
front  of  the  rectum.     The  child  should  be  anaesthetised 


DISEASES    OF    THE   BLADDER  449 

before  a  sound  is  passed  ;  its  bladder  should  be  emptied 
by  means  of  a  catheter,  and  should  then  be  moderately 
distended  with  a  solution  of  boric  acid,  15  grains  to  the 
ounce,  at  a  temperature  of  100°  F.  Two  to  four  ounces  of 
such  a  solution  are  usually  quite  sufficient  for  a  child  of 
twelve  years  old. 

Treatment. — As  soon  as  the  presence  of  the  stone  has 
been  ascertained,  the  question  arises  as  to  how  it  should  be 
extracted.  There  was  but  one  answer  to  this  question 
until  1885,  for  until  that  year  lateral  lithotomy  was  always 
performed  and  with  excellent  results.  The  labours  of 
Keegan,  Freyer,  and  Keith  in  India,  and  of  Walsham  in 
England,  have  shown  that  even  more  perfect  results  can  be 
attained  by  litholapaxy  or  lithotrity  at  a  single  sitting. 

Many  surgeons  prefer  the  suprapubic  or  high  operation 
to  either  of  the  previous  methods.  Litholapaxy  in  skilled 
hands  undoubtedly  yields  the  best  results.  Those  who 
have  had  the  largest  experience  are  able  to  employ  it  in 
nearly  every  instance;  but  it  requires  somewhat  more 
ability  than  is  possessed  by  the  surgeon  who  has  not  the 
good  fortune  to  reside  in  a  district  where  the  operation  is 
of  every-day  occurrence.  The  suprapubic  or  lateral  opera- 
tion is  therefore  better  adapted  fa-  ordinary  use;  and 
because  many  operators  are  deficient  in  boldness,  suprapubic 
lithotomy  is  often  preferred.  Litholapaxy  aims  at  remov- 
ing the  whole  of  the  stone  from  the  bladder  at  a  single 
sitting,  and,  ideally,  by  a  single  introduction  of  the  litho- 
trite.  In  children,  calculi  up  to  60  grains — about  the  size 
of  a  Spanish  nut — give  the  best  results,  though  stones  as 
large  as  an  almond  and  weighing  three  drachms  may 
readily  be  removed,  and  in  skilled  hands  very  much  larger 
ones  have  been  crushed,  for  Brigade-Surgeon  Keegan  re- 
ports the  successful  destruction  of  mho  weighing  703  graius 
in  a  boy  of  twelve. 

I!     Q 


450      THE    SURGICAL    DISEASES    OF    CHILDREN 


Pig.  52.— Lithotrite,  with  evacuator,  obturator  and  catheter,  for  performing 
the  operation  of  litholapaxy.  (From  Surgeon-Major  Freyer's  paper  in  the 
British  Medical  Journal,  1894,  ii.,  p.  1294.) 

The  instruments  (fig.  52)  must  be  of  first-rate  quality, 
and  no  expense  or  exertion  should  be  spared  to  ensure  this, 


DISEASES    OF    THE    BLADDER  45  I 

as  the  worst  accidents  have  followed  upon  a  want  of  temper 
in  the  lithotrite.  The  lithotrite  selected  should  he  the 
largest  which  can  be  introduced  into  the  urethra  with- 
out force,  and  if  necessary  the  meatus  may  be  incised 
to  facilitate  its  entrance.  Nos.  5-8  are  the  sizes  most 
frequently  required  for  children  over  two  years  of  age.  It 
is  important,  too,  to  have  the  lithotrite  fully  fenestrated, 
as  it  is  never  used  to  extract  fragments  of  the  stone,  and 
every  particle  should  drop  away  from  it  before  it  is  with- 
drawn from  the  bladder. 

The  evacuating  catheter  should  only  be  slightly  curved, 
and  must  be  provided  with  a  capacious  eye  close  to  the  end 
and  on  its  concave  surface.  An  obturator  or  stylet  should 
fit  accurately  along  its  whole  extent,  for  it  is  essential  to 
the  success  of  the  operation  that  no  fragment  of  stone 
should  become  impacted  in  the  eye,  lest  the  urethra  be 
lacerated  as  the  catheter  is  withdrawn. 

The  evacuator  should  be  in  good  working  order  and  not 
too  stiff.  It  is  almost  superfluous  to  say  that  everything 
must  be  aseptic. 

The  child  is  first  anaesthetised  ;  and  as  the  operation  is 
often  a  prolonged  one,  he  may  be  put  upon  a  warm  water- 
bed.  He  is  then  placed  in  the  Trendelenburg  position 
(p.  391),  or  his  hips  are  raised  by  placing  a  pillow  beneath 
them,  so  that  the  stone  lies  upon  the  posterior  part  of  the 
floor  of  the  bladder  rather  than  upon  its  trigone.  The 
urine  is  drawn  off,  and  the  bladder  is  distended  with  four 
ounces  of  a  saturated  solution  of  boric  acid  at  the  tempe- 
rature of  the  body.  The  lithotrite  is  introduced  after  in- 
cising the  meatus;  and  if  the  operator  possess  a  moderate 
familiarity  with  the  instrument,  there  is  usually  no  diffi- 
culty in  grasping  the  stone. 

The  calculus  should  be  reduced  to  the  condition  of  fine 
sand,  and  every  single  particle  must  be  withdrawn  by  the 


45 2      THE    SURGICAL    DISEASES    OF    CHILDREN 

evacuator,  even  though  the  operation  last  more  than  an 
hour.  The  complete  removal  of  every  particle  is  of  such 
importance  that  Mr.  J.  H.  Morgan  suggests  that,  if  there 
is  any  doubt,  it  is  as  well  to  introduce  the  evacuator  and 
wash  out  the  bladder  three  or  four  days  after  the  opera- 
tion. 

The  patient  usually  recovers  rapidly  from  the  shock,  and 
is  fit  to  go  home  in  two  or  three  days. 

The  dangers  attending  the  operation  are  :  rupture  of 
the  bladder,  laceration  of  the  urethra,  and  faulty  crushing. 
The  error  in  crushing  may  be  that  too  large  or  too  hard  a 
stone  is  selected  ;  in  such  a  case  the  operator  had  better 
perform  a  suprapubic  lithotomy  without  delay.  The  more 
frequent  error  is  that  the  stone  is  not  completely  removed, 
and  the  fragments  left  in  the  bladder  act  as  nuclei  for  the 
formation  of  fresh  calculi.  Recurrence  is  extremely  rare 
when  the  operation  has  been  performed  by  the  more  skilful 
lithotritists. 

Suprapubic  Lithotomy  appears  to  be  especially  well 
suited  for  children,  male  as  well  as  female  ;  for  in  children 
the  bladder  is  long  and  narrow,  extending  above  the  pubes 
for  a  greater  distance  than  in  adults.  The  operation  is 
therefore  an  easy  one,  and  is  resorted  to  by  those  who  have 
not  had  a  large  experience  in  lithotrity,  and  who  object 
to  lateral  lithotomy  on  the  ground  that  the  reproductive 
functions  are  endangered  by  the  bruising  or  division  of  one 
ejaculatory  duct  by  the  incision,  and  the  risk  of  injury  to 
the  other  in  extracting  the  stone.  The  child  is  placed  in 
the  Trendelenburg  position  (p.  391),  upon  a  warm  water- 
bed,  after  his  rectum  has  been  emptied  by  means  of  an 
enema.  He  is  anaesthetised,  and  his  urine  is  drawn  off  with 
a  sterilised  catheter.  A  saturated  solution  of  warm  boric 
acid  is  then  gently  injected  into  the  bladder  until  the  out- 
line of  the  organ  is  dimly  visible  above  the  pubes,— four 


DISEASES    OF    THE    BLADDER  453 

to  six  ounces  are  visually  quite  sufficient, — and  a  piece  of 
drainage-tube  is  tied  round  the  root  of  the  penis  to  prevent 
the  escape  of  the  fluid.  There  is  no  need  to  put  a  Peter- 
sen's bag  into  the  rectum. 

The  centre  of  the  upper  border  of  the  symphysis  pubis  is 
next  determined  with  precision.  An  incision  two  inches 
in  length  is  then  made  through  the  skin,  so  that  its  lower 
half-inch  lies  over  the  centre  of  the  symphysis.  The 
incision  is  deepened  until  the  recti  muscles  are  seen.  The 
recti  are  separated  from  each  other,  or  their  fibres  are 
divided  parallel  to  the  incision  and  in  its  whole  extent. 
They  are  afterwards  held  aside  by  small  retractors.  The 
peri-vesical  tissue  is  usually  of  considerable  thickness,  and 
very  vascular.  It  is,  under  ordinary  conditions,  divided 
cleanly  with  the  knife,  and  with  as  little  disturbance  as 
possible,  the  scalpel  being  laid  aside  from  time  to  time, 
so  that  the  surgeon  may  assure  himself  as  to  the  exact 
position  of  the  upper  border  of  the  symphysis  pubis,  lest 
unawares  he  be  working  too  high  and  injure  the  peritoneum. 

There  is  usually  no  difficulty  in  recognising  the  denser 
and  more  vascular  wall  of  the  bladder,  and  as  soon  as  it  is 
seen,  it  is  steadied  with  the  fingers,  and  two  aseptic  silk 
ligatures  are  passed  transversely  through  its  muscular  wall, 
one  at  the  upper  limit  of  the  wound,  the  other  immediately 
above  the  symphysis.  The  ligatures  are  held  taut  by  an 
assistant,  and  the  surgeon  plunges  his  scalpel  into  the 
bladder  wall  and  divides  it  vertically  from  above  down- 
wards through  its  mucous  as  well  as  its  muscular  coat. 
Fluid  at  once  escapes,  a  linger  is  introduced,  the  stone  is 
felt,  and  is  removed  by  a  pair  of  forceps.  The  wound  in 
the  bladder  may  be  closed  at  once  with  two  or  three 
catgut  sutures  by  Lembert's  method,  if  the  urine  be  normal 
and  there  is  no  cystitis — the  usual  condition  in  children 
The  external  wound  may  also  be  closed  in  such  cases,  and 


454      THE    SURGICAL    DISEASES    OF    CHILDREN 

an  attempt  made  to  obtain  union  by  first  intention,  the 
urine  being  repeatedly  drawn  off  with  a  soft  rubber 
catheter. 

Drainage  of  the  bladder  must  be  adopted  when  the 
urine  is  unduly  foul,  and  Prof.  Senn  recommends  that 
in  such  cases  the  operation  should  be  performed  in  two 
stages.  The  bladder  is  first  exposed,  and  the  peri-vesical 
fat  is  dissected  away  over  an  oval  space  with  its  long  axis 
vertical.  The  wound  is  then  packed  with  iodoform  gauze, 
and  dressings  are  applied  for  four  to  six  days,  until  plenty 
of  granulations  have  been  formed.  The  risk  of  septic 
absorption  is  thus  reduced  to  a  minimum.  The  bladder 
can  then  be  opened  in  the  ordinary  way  after  its  wall  has 
been  painted  with  cocain.  In  these  cases  of  foul  urine, 
Mr.  Southam  suggests  that  the  bladder  may  be  irrigated 
satisfactorily  by  drawing  the  bladder  above  the  pubes,  and 
by  afterwards  introducing  the  nozzle  of  a  Higginson's 
syringe  into  the  urethra,  and  thus  washing  out  the  bladder 
per  urethram.  By  this  method  of  "  urethral  irrigation," 
which  should  be  practised  daily  until  the  wound  has  healed, 
a  current  of  boric  lotion  is  passed  right  through  the 
bladder,  entering  at  its  base  and  leaving  at  the  suprapubic 
opening,  so  that  it  is  washed  out  very  effectually. 

The  operation  of  lateral  lithotomy  has  not  undergone 
any  modification ;  and  as  the  various  steps  are  described  in 
every  text-book  on  surgery,  and  with  especial  reference  to 
the  peculiarities  of  the  operation  in  children,  it  will  not  be 
further  considered  in  this  book. 

Prostatic  Calculi. 

Prostatic  calculi  occasionally  occur  in  children ;  but  they 
must  of  necessity  be  extremely  rare,  owing  to  the  rudi- 
mentary state  of  the  gland. 


DISEASES    OF    THE    BLADDER  455 

Urethral  Calculi. 

Urethral  calculi  are  not  uncommon,  and  are  generally 
vesical  calculi  which  have  become  impacted  either  in  the 
membranous  or  penile  portions ;  much  more  rarely  they 
are  formed  in  the  urethra  itself.  They  may  give  rise  to 
complete  retention  of  urine,  and  they  are  readily  diagnosed 
by  the  passage  of  a  sound  into  the  urethra.  When  a 
calculus  is  so  firmly  impacted  that  it  can  neither  be 
pushed  back  into  the  bladder  nor  withdrawn  by  the 
urethral  forceps,  it  may  be  necessary  to  incise  the  penis 
longitudinally  along  its  under  surface.  This  method, 
however,  should  only  be  adopted  as  a  last  resource,  as  I 
have  seen  a  troublesome  penile  fistula  result  from  it. 

Pr/eputial  Calculi. 

Preputial  calculi  are  sometimes  found  in  the  corona 
glandis  during  the  performance  of  circumcision.  They 
are  usually  calcified  masses  of  smegma.  In  a  few  cases 
they  may  have  escaped  from  the  bladder,  and  Dr.  William 
Hunt  therefore  suggests  that  when  they  are  met  with  the 
child  should  be  sounded. 

TUMOURS   OF   THE  BLADDER. 

Myxomata  and  papillomata  are  less  frequent  in  the 
bladders  of  children  than  sarcomata.  A  primary  cancer 
has  only  once  been  recorded. 

Symptoms. — Vesical  tumours  cause  difficulty  in  mic- 
turition, with  pain  either  during  or  occurring  independently 
of  the  passage  of  urine.  Hematuria,  although  it  is  some- 
times profuse,  is  less  frequent  and  is  not  so  marked  a 
symptom  as  in  adults.  It  sometimes  commences  spon- 
taneously, but  it  is  more  often  observed  for  the  first  time 


45^      THE    SURGICAL    DISEASES    OF    CHILDREN 

after  the  child  has  been  sounded  or  has  had  a  catheter 
passed.  The  flow  of  urine  is  often  impeded,  and  there  is 
sometimes  complete  retention.  The  difficulty  of  micturi- 
tion, in  the  later  stages,  may  lead  to  the  establishment  of 
a  fistulous  tract  in  very  young  children,  for  the  remains 
of  the  allantois  may  re-open,  so  that  the  urine  is  voided 
through  the  umbilicus. 

Diagnosis. — The  great  capacity  for  dilatation  possessed 
by  the  female  urethra  always  allows  the  tumour  to  protrude 
from  a  girl's  vulva,  and  so  renders  the  symptoms  less  acute 
and  the  diagnosis  easy.  In  boys,  where  no  such  dilatation 
is  possible,  the  symptoms  are  often  mistaken  for  those 
caused  by  a  stone  in  the  bladder ;  nor  is  it  easy  to  distin- 
guish them.  The  urine  hardly  ever  contains  fragments  of 
the  growth,  and  the  passage  of  a  sound  may  reveal  a 
tumour  which  seems  so  hard  that  it  is  readily  mistaken 
for  a  stone.  Rectal  and  bimanual  examination  under  an 
anaesthetic  will  often  enable  the  surgeon  to  detect  an 
enlarged  bladder  with  thickened  walls,  though  the  result 
of  such  an  examination  may  be  negative.  The  distension 
of  the  bladder  may  be  mistaken  for  retention,  but  it  is  due 
to  the  infiltration  of  its  walls  with  sarcomatous  tissue,  for 
the  organ  does  not  contain  much  urine,  and  it  may  remain 
distended,  even  after  it  has  been  laid  open.  In  some  cases 
the  growth  of  the  tumour  causes  paralysis  of  the  muscular 
walls  of  the  bladder,  and  the  urine  may  then  accumulate 
in  it. 

Treatment. — The  injection  of  a  solution  of  1  in  5,000  of 
perchloride  of  mercury  at  a  temperature  of  100°  F.  often 
relieves  the  dysuria,  especially  if  cystitis  be  present ;  and, 
if  necessary,  its  strength  may  be  gradually  and  cautiously 
increased.  In  girls  an  attempt  may  be  made  to  remove 
the  tumour  through  the  urethra,  but  in  boys  a  suprapubic 
cystotomy   must   be  performed  if   the  symptoms  become 


DISEASES    OF    THE    BLADDER  457 

urgent,    and   the   growth   must   be   removed   by   cutting 
forceps. 

Prognosis. — The  result  of  the  operation  in  boys  is  so 
disastrous  that  it  is  only  performed  as  a  last  resource,  and 
in  girls  nearly  all  attempts  to  remove  malignant  growths 
have  terminated  fatally  within  a  few  months,  for  the 
sarcomata  of  the  bladder  follow  the  ordinary  rule  that  in 
children  all  malignant  growths  run  a  very  rapid  course. 


CHAPTER  XXIII 

SURGICAL  AFFECTIONS  OF  THE  URETHRA 

RUPTURED  URETHRA.54 

Causes.  —  Rupture  of  the  urethra  takes  place  rather 
frequently  in  boys  from  direct  violence,  as  by  falling 
astride  a  bar,  whilst  sliding  downstairs,  or  from  a  kick 
upon  the  perineum  ;  but  it  is  sometimes  the  result  of 
indirect  violence,  or  it  is  a  complication  of  fractured 
pelvis. 

The  rupture  is  either  partial  or  complete,  and  its 
diagnosis  is  usually  so  easy  that  it  is  not  likely  to  be 
mistaken  for  any  other  injury. 

Symptoms. — There  is  generally  severe  pain,  with 
greater  or  less  difficulty  in  passing  water.  A  tense  and 
tender  swelling  forms  in  the  perineum,  and  there  may  or 
may  not  be  bleeding  from  the  orifice  of  the  penis. 

Treatment. — The  treatment  in  the  slightest  forms, 
where  micturition  is  not  interfered  with,  when  there 
is  little  or  no  bleeding,  and  when  the  perineal  swelling 
is  very  small,  must  be  expectant,  for  it  is  possible  that  the 
urethra  may  only  be  bruised.  The  boy  must  be  put  to 
bed,  and  the  swollen  perineum  must  be  carefully  watched, 
to  see  that  no  suppuration  or  extravasation  of  urine  takes 
place. 

If  the  temperature  rises,  the  perineal  hsematoma  should 
be  incised,  the  clot  turned  out,  and  its  cavity  cleansed. 

458 


SURGICAL    AFFECTIONS    OF    THE    URETHRA     459 

The  condition  of  the  urethra  should  be  examined  at  the 
same  time ;  if  it  is  partially  lacerated  or  completely 
torn,  the  two  ends  must  be  found  and  united.  It  is 
always  easy  to  find  the  anterior  extremity,  for  a  catheter 
can  be  passed  through  it  along  the  penis ;  but  it  may  be 
impossible  to  discover  the  posterior  portion.  The  search 
is  facilitated  in  such  cases  by  remembering  that  the 
posterior  portion  of  the  urethra  generally  lies  nearer  to 
the  anus  than  the  penile  part,  and  pressure  upon  the 
bladder  will  often  enable  the  surgeon  to  squeeze  a  few 
drops  of  urine  along  the  urethra,  and  this  will  serve  to 
indicate  the  position  of  the  vesical  portion. 

It  is  considered  advisable  by  some  surgeons  to  pass 
a  rigid  catheter  along  the  urethra  into  the  bladder. 
They  then  perform  suprapubic  cystotomy.  The  bladder 
being  opened  upon  the  point  of  the  catheter,  the  open- 
ing should  be  enlarged  until  it  easily  admits  a  large- 
sized  drainage-tube.  The  catheter  should  be  withdrawn, 
and  as  many  sutures  inserted  into  the  urethra  as  seem 
to  be  necessary.  Four  are  generally  sufficient  for  a  com- 
plete rupture :  one  in  the  roof,  one  in  each  side,  and  one 
in  the  floor.  The  suture  in  the  roof  should  be  tied  first. 
As  large  a  catheter  as  the  urethra  will  admit  should 
be  passed,  to  support  the  wounded  edges,  and  to  prevent 
them  from  folding  inwards.  The  remaining  sutures  are 
tied  in,  and  the  catheter  is  removed  with  the  greatest 
care,  so  that  its  point  does  not  stick  either  into  the  roof 
or  into  the  floor  at  the  sutured  part.  The  whole  or  part 
of  the  perineal  wound  may  then  be  brought  together. 

The  suprapubic  drainage  may  be  continued  for  ten 
days;  ami  during  this  time  no  catheter  should  be  passed, 
and  no  urine  should  be  allowed  to  flow  through  the 
urethra.  The  bowels  may  be  kept  conh'ned  for  a  week. 
It  is  difficult,  even  in  children,  to  obtain  union  by  first 


460      THE    SURGICAL    DISEASES    OF    CHILDREN 

inteution  in  these  cases.  When  there  has  been  extensive 
laceration,  and  the  ends  of  the  urethra  cannot  be  brought 
together,  a  catheter  may  be  passed  into  the  bladder,  and 
the  deep  perineal  tissues  may  be  sutured  round  it,  the 
catheter  being  left  in  position  as  long  as  possible.  Repair 
eventually  takes  place,  and  the  amount  of  dilatation 
required  to  prevent  the  formation  of  a  traumatic  stricture 
is  so  much  less  after  operation  than  after  the  ordinary 
methods  of  treatment  have  been  adopted,  that  it  is  quite 
worth  while  to  suture  the  urethra  in  these  cases. 

PROLAPSE  OP  THE  FEMALE  URETHRA.55 

There  are  several  cases  on  record  in  which  the  urethra 
in  little  girls  has  become  prolapsed. 

etiology.— The  exciting  causes  leading  to  the  con- 
dition are  unknown ;  but  the  predisposing  causes  are 
general  weakness,  local  irritation  at  the  neck  of  the 
bladder,  and  repeated  straining,  associated  with  chronic 
cough  or  with  habitual  constipation. 

Symptoms.— The  symptoms  are  never  acute,  and  the 
condition  often  passes  unnoticed  for  long  periods  of  time. 
There  may  be  increased  frequency  of  micturition,  with 
scalding  and  sometimes  bleeding.  Examination  of  the 
vulva  shows  the  presence  of  a  red  mass,  which  may  be 
furrowed  with  longitudinal  ridges,  and  which  presents 
a  central  depression  forming  the  orifice  of  the  urethra. 

Diagnosis. — The  prolapse  may  be  mistaken  for  a 
nsevus,  polypus,  or  for  a  urethral  caruncle. 

Treatment. — Simple  replacement,  as  in  Mr.  Bryant's 
case,  is  sometimes  sufficient  to  cure  the  prolapse ;  and  in 
other  cases,  washing  with  cold  water,  and  the  occasional 
application  of  solid  nitrate  of  silver,  causes  sufficient 
constriction    to   prevent  any  recurrence.      Guersant   has 


SURGICAL    AFFECTIONS    OF    THE    URETHRA    46 1 

obtained  satisfactory  results  by  drawing  forward  the 
prolapsed  portion  with  a  tenaculum,  and  then  snipping 
it  off. 

PHIMOSIS.56 

Phimosis,  in  its  strict  sense,  is  that  condition  in  which 
the  prepuce  is  unduly  long,  and  its  orifice  is  so  narrow  that 
it  cannot  be  retracted ;  but  the  term  is  often  applied  to 
those  cases  in  which,  from  a  persistence  of  the  foetal  con- 
dition, the  prepuce  is  more  or  less  firmly  attached  to  the 
glans  penis. 

Sequelae. — Phimosis  often  leads  to  urinary  troubles, 
either  in  the  shape  of  dysuria  and  retention  of  urine,  or, 
in  its  more  advanced  forms,  to  thickened  and  contracted 
bladder,  with  hydronephrosis  (fig.  55).  Extravasation  of 
urine  in  infants  is  an  occasional  result  of  phimosis.  It 
may  also  be  the  cause  of  balanitis,  and  more  remotely 
of  umbilical  and  inguinal  hernia,  though  there  are  many 
good  reasons  for  thinking  that  phimosis  does  not  usually 
stand  in  any  direct  causal  relation  to  hernia.  It  is  said 
to  lead  to  the  more  common  forms  of  hydrocele,  whilst 
masturbation  and  sexual  incontinence  may  be  associated 
with  its  presence.  In  many  cases  the  orifice  in  the 
prepuce  is  not  opposite  the  urinary  meatus,  so  that 
when  the  child  passes  urine,  the  prepuce  is  distended  into 
a  transparent  sac,  and  he  is  then  promptly  brought  for 
surgical  treatment. 

Treatment. — When  the  orifice  of  the  prepuce  is  wide, 
and  the  adhesions  are  few,  a  cure  may  often  be  wrought 
by  retracting  the  prepuce,  separating  all  the  adhesions, 
and  clearing  away  the  smegma  which  has  been  secreted 
into  the  furrow  behind  the  glans. 

Forcible  dilatation  of  the  prepuce  in  true  phimosis  is 
useless.     I  tried  it  most  thoroughly,  and  in  many  cases, 


462      THE    SURGICAL    DISEASES    OF    CHILDREN 

for  a  year,  and  satisfied  myself  that  it  was  a  failure. 
The  prepuce  cannot  be  retracted  without  either  partially 
or  completely  rupturing  it.  The  ruptures  often  heal 
badly,  or  cause  a  chronic  irritation,  which  leads  to  so 
much  induration  as  to  require  removal  of  the  prepuce. 
I  therefore  content  myself  with  circumcision  in  cases 
of  phimosis,  though  it  is  by  no  means  necessary  to  per- 
form it  on  every  child,  or  even  on  the  majority  of  children 
who  have  a  long  and  narrow  foreskin. 

Circumcision. 

Circumcision  is  performed  at  any  age,  so  long  as  the 
child  is  healthy.  The  ideal  to  be  aimed  at,  as  in  all 
plastic  operations,  is  to  obtain  so  good  a  result  that  the 
fact  of  surgical  intervention  having  been  necessary  is 
not  at  once  apparent ;  and  to  obtain  such  a  result,  union 
by  first  intention  is  of  the  utmost  importance.  The 
operation  is  so  frequent  in  children  that  each  surgeon  has 
his  own  way  of  performing  it.  It  is  sometimes  required 
for  balanitis,  and  more  rarely  after  paraphimosis.  The 
method  I  usually  adopt  is  to  render  the  parts  aseptic,  and, 
if  possible,  to  retract  the  foreskin  and  carefully  clean 
away  all  the  smegma  preputii. 

The  child  is  anaesthetised,  and  an  assistant  grasps  the 
\  root  of  the  penis  to  arrest  bleeding  and  to  fix  the  skin 

against  the  pubes.  The  foreskin  is  then  pulled  forwards, 
and  is  cleanly  snipped  off  with  a  pair  of  scissors  immedi- 
ately in  front  of  the  glans;  the  incision  being  carried 
obliqixely  forwards  from  the  dorsum  to  the  frsenum. 
The  mucous  membrane  of  the  prepuce  is  now  seen  as  a 
raw  surface,  covering  the  glans ;  it  is  separated  from  the 
corona  by  passing  a  probe  or  director  through  its  orifice. 
This  is  generally  easy,  for  the  adhesions  are  slight :  but 
the  prepuce  has  sometimes  to  be  actually  dissected  off  the 


SURGICAL    AFFECTIONS    OF    THE    URETHRA    463 

glans,  and  at  other  times  its  margin  is  continuous  with 
the  urethral  mucous  membrane.  These  cases  are  often 
very  unsatisfactory,  for  the  prepuce  contracts  fresh 
adhesions  to  the  raw  surface  of  the  glans,  or  the  orifice 
of  the  urinary  meatus  afterwards  contracts,  and  when  it 
has  been  slit  up,  again  contracts. 

There  is  usually  no  difficulty  in  separating  the  mucous 
membrane  of  the  prepuce  from  the  glans.  As  soon  as  the 
separation  is  complete,  the  preputial  mucous  membrane  is 
divided  longitudinally  either  with  a  scalpel  or  with  a  pair 
of  blunt-pointed  scissors,  taking  care  that  the  urethra  is 
not  cut  at  the  same  time.  The  mucous  membrane  is  then 
turned  to  either  side,  the  smegma  preputii  is  removed, 
and  the  sulcus  is  thoroughly  cleaned  with  pieces  of  wet 
absorbent  wool. 

The  preputial  mucous  membrane  is  next  cut  away,  near 
the  glans,  but  not  absolutely  on  a  level  with  it ;  for  after 
a  well-performed  circumcision  there  should  be  a  slight 
but  sufficient  covering  for  the  lower  part  of  the  glans,  and 
there  should  not  be  the  tight  retraction  with  disappearance 
of  the  sulcus  which  is  too  frequently  seen  after  the  opera- 
tion. 

The  frsenum  in  many  cases  may  be  left  untouched  ;  but 
if  the  tissue  in  its  neighbourhood  appears  to  be  redundant, 
I  do  not  hesitate  to  trim  it  up  ;  and  if  it  be  too  short,  as 
is  often  the  case,  it  may  be  entirely  removed,  and  a  new 
one  formed.  Dr.  Felizet's  method  is  a  good  one  for  this 
purpose.  The  penis  is  raised  so  as  to  expose  the  trian- 
gular raw  surface  on  the  under  surface  of  the  glans  (fig. 
53).  Two  horsehair  sutures,  1  and  2,  are  then  passed 
through  the  edges  of  the  skin.  The  suture  (1)  nearest  the 
meatus  is  tied  in  a  reef-knot,  and  cut  short. 

The  lower  suture  (fig.  54,  2)  is  tied  in  a  "  granny," 
so  that  the  ends  lie  parallel  with  the  line  of   incision. 


464      THE    SURGICAL    DISEASES    OF    CHILDREN 

A  needle  is  again  threaded  to  the  lower  end  of  the  suture 
(fig.  54,  3),  and  is  made  to  traverse  the  cut  margin  of  the 
skin  of  the  penis.  It  is  then  tied  to  the  upper  end  of  the 
lower  suture  (fig.  54,  2),  and  by  this  means  the  skin  of 
the  penis  is  approximated  to  the  glans. 

The  assistant  now  relaxes  his  hold  on  the  root  of  the 
penis,  and  the  bleeding  is  arrested.  This  is  rather  sharp 
in  young  children,  and  I  attach  the  greatest  importance 
to  its  complete  arrest,  as  iinion  by  first  intention  cannot 
be  obtained  when  the  two  cut  edges  of  the  wound  are 


Fig.  53. 


Fig.  51. 


Figs.  53,  51.— Diagrams  showing  Felizet's  method  of  forming  a  new  frsennm 
during  the  operation  of  circumcision. 


It  is  therefore  worth  while  to 
in   stopping   it.     The   bleeding 

These 


separated  by  blood-clot. 

take  some  little   trouble 

usually  takes  place  from  the  artery  of  the  fraenum 

often  need  a  very  fine  catgut  ligature,  whilst  the  venous 

haemorrhage,   which    is   sometimes   troublesome,   may   be 

stopped  by  pressure  forceps. 

The  parts  are  then  gently  irrigated  with  a  solution 
of  boric  acid  or  perchloride  of  mercury ;  and  when  the 
operation  has  been  performed  upon  a  healthy  child  with 
an  uninflamed  prepuce,  it  is  usually  sufficient  to  slide  the 


SURGICAL    AFFECTIONS    OF    THE    URETHRA      465 

skin  forwards  over  the  mucous  membrane,  so  that  the  two 
raw  edges  are  in  contact.  The  part  is  dried,  and  a  single 
strip  of  cyanide  gauze  is  wrapped  round  the  wound,  and 
painted  over  with  collodion,  taking  care  to  leave  the 
meatus  patent.  If  the  foreskin  has  been  inflamed,  it  is 
better  to  unite  the  edges  of  the  wound  at  one  or  two 
points  with  sutures  of  horsehair. 

The  dressing  is  completed  by  passing  the  penis  through 
a  hole  in  the  centre  of  a  piece  of  absorbent  cotton-wool  or 
of  Gramgee  tissue.  It  is  then  slung  against  the  abdomen 
by  means  of  a  piece  of  strapping,  which  is  sufficient  to 
keep  it  raised,  but  is  not  applied  tightly  enough  to  cause 
any  risk  of  strangulation,  even  though  the  organ  should 
become  swollen.  The  thighs  and  knees  should  be  lightly 
lnund  together  for  a  few  hours  after  the  operation,  to 
prevent  the  dressings  being  disturbed. 

After-Treatment.  —  The  after-treatment  consists  in 
keeping  the  child  at  rest  until  the  wound  is  healed.  The 
dressings  will  not  require  changing  until  the  second  or 
third  day,  if  directions  be  given  to  the  child's  attendant  to 
prevent  their  becoming  soiled ;  at  the  expiration  of  this  time 
they  are  allowed  to  soak  off  in  a  warm  bath.  It  may  be 
necessary  to  reapply  them,  or  it  may  be  sufficient  to  dust 
the  penis  with  nitrate  of  bismuth  after  bathing  it  in  a 
weak  solution  of  corrosive  sublimate.  I  do  not  consider  it 
necessary  for  a  child  whose  urine  is  healthy  to  micturate 
with  its  penis  in  an  antiseptic  solution,  as  many  surgeons 
recommend. 

Accidents. — The  operation  is  usually  straightforward, 
but  a  due  proportion  of  accidents  attend  it.  A  certain 
amount  of  shock  is  often  noticed  during  the  period  of 
anaesthesia.  It  is  most  often  seen  in  the  ill-fed,  and  in 
children  who  have  been  kept  too  long  without  food.  Daring 
the  operation,  when  the  prepuce  is  adherent  to  the  epithe- 

11  H 


466      THE    SURGICAL    DISEASES    OF    CHILDREN 

lial  lining  of  the  urethra,  the  mucous  membrane  must  be 
picked  up  with  a  pair  of  toothed  forceps,  and  carefully 
incised  along  the  dorsum  of  the  penis ;  it  must  then  be  cut 
circularly,  and  its  anterior  portion  dissected  away  from  the 
urethral  orifice.  In  other  cases  the  prepuce  may  be  so 
hypertrophied,  as  a  result  of  chronic  inflammation,  that  the 
inexperienced  operator  may  dissect  too  carefully,  in  his 
anxiety  to  avoid  the  glans,  and  may  lose  himself  in  the 
indurated  tissues.  Care  must  be  taken,  on  the  other  hand, 
not  to  remove  too  much  skin  in  cases  where  the  penis  is 
very  small  and  has  become  retracted  under  the  influence 
of  cold. 

The  bleeding  is  usually  slight  and  easily  controlled  ;  but 
as  the  vessels  of  the  penis  are  very  contractile,  it  occasion- 
ally happens  that  the  operation  may  have  been  completed 
before  they  have  relaxed.  Serious  loss  of  blood  sometimes 
takes  place  from  this  cause,  as  the  haemorrhage  is  likely  to 
be  overlooked  because  the  blanching  which  it  causes  is 
attributed  to  the  effects  of  the  anaesthetic.  The  surgeon 
should  therefore  assure  himself  that  the  child  is  doing  well 
before  he  leaves  it,  or  he  should,  at  any  rate,  give  directions 
to  the  nurse  not  to  trust  too  much  to  appearances,  but 
actually  to  see  for  herself  from  time  to  time  that  the  dress- 
ings are  not  becoming  blood-stained. 

Union  by  first  intention  can  generally  be  secured,  but 
suppuration  happens  pretty  frequently,  and  with  it  a  con- 
siderable amount  of  oedema,  or  the  tissues  may  even  slough. 
In  a  few  cases  the  child  may  die  of  pyaemia  or  of  exhaus- 
tion. In  the  slighter  cases  of  suppuration,  the  penis 
should  be  repeatedly  bathed  in  a  solution  of  perchloride  of 
mercury,  and  gauze  dressings  should  be  applied  to  the  in- 
flamed part.  Stimulants  and  quinine  are  to  be  adminis- 
tered to  the  patient  in  these  cases. 

Care  should  be  taken   after  the   operation  to  see  that 


SURGICAL    AFFECTIONS    OF    THE    URETHRA      467 


''■   .    "  ' 


Fig.  65.— Bladder  and  kidneys  from  a  lad  of  17  years,  showing  the  baleful 
effects  of  an  untreated  phimosis. 

[/',-  ,■/  L':}70  (o)  in  I),.  Museum  of  SI.  Bartholomew's  Hospital.] 


468      THE    SURGICAL    DISEASES    OF    CHILDREN 

retention  of  the  urine  does  not  occur.  It  is  well  to  assure 
oneself,  before  circumcising,  that  the  kidneys  are  healthy 
in  children  who  have  had  a  tight  phimosis,  as  death  may 
occur  from  acute  suppurative  nephritis.  The  following 
case,  which  came  under  my  notice  a  few  years  ago,  well 
exemplifies  the  value  to  be  attached  to  an  examination  of 
the  urine  in  these  cases.  An  apparently  healthy  lad,  who 
acted  as  a  railway  porter  at  a  country  station,  presented 
himself  fresh  from  his  work,  and  with  so  tight  a  phimosis 
that  a  probe  could  not  be  passed  through  the  orifice  in 
the  foreskin.  He  was  circumcised,  and  two  days  later  he 
began  to  suffer  from  symptoms  of  suppression  of  urine.  He 
became  comatose,  had  ursemic  convulsions,  and  died  three 
days  after  the  operation.  The  annexed  drawing  (fig.  55) 
of  the  genito-urinary  organs  shows  how  greatly  the  bladder 
is  enlarged  and  hypertrophied.  Its  mucous  coat  is  ulcer- 
ated. The  ureters  are  enormously  distended  and  thickened, 
except  at  their  point  of  entrance  into  the  bladder,  where 
they  are  normal  in  size.  The  pelves  and  infundibula  of 
the  kidneys  are  widely  dilated,  thickened,  and  rough  from 
a  deposit  of  lymph  upon  their  inner  surfaces.  The 
glandular  substance  has  entirely  disappeared. 

A  similar  condition  of  the  genito-urinary  organs  is 
sometimes  found  after  phimosis  leading  to  incontinence  of 
urine.  Dr.  Alexander  James56  believes  that  indications 
of  this  condition  can  be  obtained  from  the  persistent  low 
specific  gravity  of  the  urine,  and  the  presence  in  it  of 
small  amounts  of  albumin.  Mr.  Burn  Murdoch  has  also 
called  attention  to  similar  cases. 

BALANO-POSTHITIS. 

The  foreskin  is  a  peculiarly  vulnerable  point  in  young 
children,  and  the  surgeon  is  constantly  consulted  about 
inflammatory  conditions  occurring  in  it.     Posthitis,  or  in- 


SURGICAL    AFFECTIONS    OF    THE    URETHRA      469 

flamination  of  the  foreskin,  is  nearly  always  associated 
with  balanitis,  or  inflammation  of  the  glans  penis,  and  it 
is  therefore  convenient  to  consider  the  two  conditions  at 
the  same  time.  Balano-posthitis  is  due  to  general  as  well 
as  to  local  conditions. 

Causes. — Phimosis  is  one  of  the  commonest  causes,  for 
it  leads  to  a  retention  of  smegma,  which  may  decompose 
beneath  the  foreskin,  or  it  sets  up  inflammation  owing 
to  the  irritation  produced  by  partial  adhesion  existing 
between  the  glans  and  the  mucous  lining  of  the  prepuce. 
The  dribbling  of  urine  over  a  long  foreskin  may  cause 
an  eczema  which  in  turn  becomes  a  balano-posthitis. 
Diabetes,  gonorrhceal  discharges,  and  soft  sores  more 
rarely  give  rise  to  this  condition  in  older  children.  Irrita- 
tion of  the  urinary  tract  from  the  presence  of  calculi  and 
from  Bilharzia,  or  of  the  rectum  from  thread-worms,  also 
causes  inflammation  of  the  foreskin.  It  may  be  produced 
by  injury,  and  it  sometimes  occurs  after  circumcision. 
The  constitutional  causes  are  the  exanthemata,  especially 
scarlet  fever  and  measles,  erysipelas, '  diphtheria  and 
tubercle,  or  rather  that  predisposition  to  tubercle  which  is 
now  called  struma.  It  also  occurs  in  those  children  of 
gouty  parents  who  have  inherited  the  uric  acid  diathesis. 

Symptoms.  —  In  the  simplest  form  the  foreskin  be- 
comes red,  swollen,  and  cedematous,  and,  if  it  be  left  un- 
treated, soon  exudes  a  clear,  serous  fluid.  The  oedema 
extends  some  distance  down  the  penis,  and  generally  ter- 
minates abruptly. 

Treatment. — This  condition  usually  subsides  if  the 
penis  be  slung  against  the  abdomen  after  it  has  been 
thoroughly  cleansed  by  giving  the  child  a  warm  bath,  and 
by  the  local  application  of  subnitrate  of  bismuth,  or  of 
equal  parts  of  starch  and  oxide  of  ziuc.  The  child  should 
be  circumcised  as  soon  as  the  acute  symptoms  have  sub- 


470      THE    SURGICAL    DISEASES    OF    CHILDREN 

sided.  The  inflammation  is  so  acute  in  some  cases  that  a 
part  or  the  whole  of  the  prepuce  may  become  gangrenous, 
or  it  may  be  sloughing  from  the  first.  These  forms 
require  much  more  active  treatment.  Two  or  three  ounces 
of  brandy  should  be  administered  daily,  with  two  minims 
of  laudanum  three  times  a  day  for  a  child  of  a  year  old. 
The  penis  should  be  raised,  and  should  be  repeatedly  bathed 
with  hot  water.  The  prepuce  should  be  slit  if  there  is 
complete  retention  ;  otherwise  no  cutting  operation  should 
be  performed  until  the  child  is  in  a  better  state  of  health. 
Suppuration  does  not  often  take  place ;  but  when  it  does, 
the  abscess  must  be  opened  at  once. 

Paraphimosis. 

Paraphimosis  occurs  more  often  in  older  children  than 
in  infants.  It  necessarily  has  a  phimosis  as  its  antece- 
dent condition. 

Symptoms. — The  symptoms  are  due  to  the  venous  con- 
gestion produced  by  a  tight  and  retracted  prepuce  whilst 
the  arteries  continue  to  carry  blood  to  the  glans.  Acute 
strangulation  is  thus  produced,  the  prepuce  becomes 
(edematous,  and  the  glans  swollen  and  congested  ;  but,  in 
spite  of  this,  gangrene  is  not  a  very  frequent  result. 
Similar  symptoms  are  produced  in  children  by  the  appli- 
cation of  ligatures  to  the  penis,  so  that  the  surgeon  should 
ascertain  that  nothing  is  tied  round  the  organ  before  he 
attempts  to  reduce  a  paraphimosis. 

Treatment. — The  treatment  of  paraphimosis  consists  in 
relieving  the  constriction  as  soon  as  possible.  This  can  be 
done  by  returning  the  prepuce  to  its  normal  position  by 
incising  it  or  by  cutting  it  off.  Reduction  is  effected  by 
placing  the  patient  on  a  bed  and  ansesthetising  him.  The 
surgeon  stands  upon  the  right  side  and  takes  the  penis 
between  the  second  and  third   fingers  of   his  left  hand, 


SURGICAL    AFFECTIONS    OF    THE    URETHRA      47  I 

whilst  he  grasps  the  swollen  glans  in  the  fingers  and 
thumb  of  his  right  hand.  He  squeezes  the  glans  with  his 
right  hand,  so  as  to  reduce  its  size  as  far  as  possible  by 
rendering  it  bloodless,  and  he  simultaneously  pulls  the 
prepuce  forward  and  pushes  the  glans  backwards  until 
reposition  is  effected.  When  this  has  been  done,  the  sur- 
geon should  be  careful  to  ascertain  that  the  reduction  is 
real  and  not  apparent,  for  it  sometimes  happens  that  the 
foreskin  is  pulled  into  place  whilst  the  preputial  mucous 
membrane  is  left  behind  and  remains  as  a  constricting 
band.  The  operation  is  often  a  long  and  difficult  one,  and 
the  foreskin  may  be  much  chafed.  To  facilitate  the  reduc- 
tion, the  glands  may  sometimes  be  emptied  of  blood  by 
bandaging  the  penis  from  its  point  towards  its  root. 

The  penis  should  be  thoroughly  washed  after  the  re- 
duction with  a  1  in  1000  solution  of  corrosive  sublimate, 
and  its  end  should  be  wrapped  in  wet  cyanide  gauze. 
The  patient  must  be  kept  in  bed  for  a  day  or  two. 

Operative  treatment  is  to  be  adopted  as  soon  as  the  sur- 
geon has  satisfied  himself  that  manipulation  is  useless.  A 
probe-pointed  bistoury  is  slipped  between  the  glans  and 
the  prepuce  along  the  dorsum  of  the  penis,  and  the  constric- 
tion is  freely  divided.  This  is  usually  sufficient  to  permit 
the  prepuce  to  be  drawn  forwards,  but  it  is  sometimes 
necessary  to  make  small  oblique  incisions  from  the  end  of 
the  dorsal  wound  before  the  prepuce  can  be  replaced.  It 
is  not  advisable  to  circumcise  immediately  after  a  paraphi- 
mosis has  been  reduced,  as  the  tissues  are  too  inflamed  to 
heal  by  first  intention. 

Dislocation  of  the  Penis.57 

The  penis  in  children  occasionally  becomes  displaced 
as  the  result  of  direct  violence,  so  that  it  lies  within  the 


472      THE    SURGICAL    DISEASES    OF    CHILDREN 

scrotum.     Reduction  lias  been  effected  by  careful  manipu- 
lation as  late  as  tlie  tenth  day  after  the  accident. 

ENURESIS.58 

Few  patients  are  more  often  seen  by  the  medical  officers 
attached  to  a  Hospital  for  Children  than  those  suffering 
from  incontinence  of  urine,  and  for  few  can  less  good  be 
done  by  treatment.  The  incontinence  is  most  frequently 
nocturnal ;  but  involuntary  passage  of  urine  during  the 
day  is  not  a  very  uncommon  affection  in  girls  between  the 
ages  of  six  and  twelve  who  are  overworked  at  school.  The 
causes  of  enuresis,  and  the  methods  recommended  for  its 
treatment,  are  nearly  as  numerous  as  the  "  piss-a-beds  " 
themselves. 

etiology. — Essentially  a  physiological  defect  con- 
nected with  an  ill-developed  sphincter  vesicse,  enuresis  is 
associated  with  phimosis,  with  constriction  of  the  urinary 
meatus,  or  with  other  parts  of  the  urethra,  and  with 
chronic  irritation  of  the  bladder,  rectum,  or  urethra  by 
vesical  growths,  worms,  or  stone.  It  is  met  with  in  con- 
nection with  chronic  nephritis  and  pyelitis,  with  renal 
and  vesical  calculus,  and  with  alterations  in  the  specific 
gravity  and  in  the  reaction  of  the  urine.  It  may  also,  and 
more  rarely,  be  associated  with  disorders  of  the  central 
nervous  system,  characterised  by  epilepsy  and  night  terrors, 
or  with  congenital  defects  of  the  spinal  cord,  associated 
with  spina  bifida,  either  of  the  ordinary  type  or  in  the  less 
common  form  of  spina  bifida  occulta.  It  may  occur  as  an 
early  symptom  of  diabetes,  and  I  have  seen  it  rather  fre- 
quently associated  with  slight  but  chronic  cystitis,  pre- 
sumably tuberculous  in  origin,  and  in  some  early  cases  of 
Pott's  disease  of  the  spine.  It  is,  perhaps,  most  often  met 
with  in  the  two  extreme  types  of  intellectually  developed 


SURGICAL   AFFECTIONS    OF    THE    URETHRA      473 

children — those  who  are  unduly  bright,  precocious,  and 
excitable,  and  in  those  who  are  of  low  mental  calibre. 

Treatment. — The  affection  is  a  very  obstinate  one,  but 
it  should,  as  far  as  possible,  be  treated  causally.  When 
no  cause  can  be  detected,  the  passage  of  as  large  a  sound 
as  the  urethra  will  admit  is  often  followed  by  good  results, 
especially  if  the  sound  is  cooled  by  being  placed  upon  ice 
before  it  is  oiled.  This  treatment,  first  used  by  Mr. 
Edmund  Owen,  has  recently  been  placed  upon  a  scientific 
footing  by  Prof.  Peyer,  who  shows  that  it  is  most  service- 
able in  cases  of  chronic  irritation  of  the  prostatic  portion 
of  the  urethra — a  condition  which  is  often  found  in  boys 
who  masturbate.  It  is  indicated  by  the  presence  of  a  con- 
siderable quantity  of  clear  mucus  entangling  crystals  of 
triple  phosphates  in  the  sediment  of  urine  which  has  been 
allowed  to  stand  for  a  few  hours  in  a  conical  glass  vessel. 
Epithelial  cells,  leucocytes,  and,  in  older  boys,  more  or  less 
well-developed  spermatozoa  repeatedly  found  in  the  urinary 
deposit,  will  go  far  towards  establishing  a  diagnosis  of 
masturbation.  The  sound  in  these  cases  should  be  passed 
at  least  twice  a  week  ;  but  in  bad  cases  it  may  be  necessary 
to  perform  the  operation  daily.  It  should  be  left  in  the 
urethra  for  five  minutes  on  each  occasion. 

The  ordinary  adjuvants  to  treatment  must  be  adopted 
in  every  case,  such  as  tonics,  waking  the  child  to  pass 
water  when  its  attendant  goes  to  bed,  giving  it  light  and 
•  ligestible  meals  with  a  minimum  of  fluid  in  the  daytime, 
and  none  in  the  evening.  The  general  tone  of  the  system 
may  be  improved,  with  benefit  to  the  local  defect,  by  spong- 
ing the  body  with  sea-water,  and  then  briskly  rubbing  it 
with  a  bath-towel  until  a  glow  is  felt.  It  is  often  advis- 
able also  to  prevent  the  child  sleeping  upon  his  back. 

I  have  only  obtained  good  results  in  the  slightest  cases 
from  the  administration  of  belladonna  even  in  large  doses, 


474      THE    SURGICAL    DISEASES    OF    CHILDREN 

and  when  mixed  with  mix  vomica ;  but  the  treatment 
should  always  be  tried  before  other  measures  are  adopted. 
Dr.  Baruch's  method,  recommended  by  Mr.  Edmund  Owen 
in  his  Lettsomian  lectures,  is  easy  to  recollect,  and  is  as 
satisfactory  a  way  of  administering  the  drug  as  any  other. 
He  orders — 

I£.  Atropise  sulphatis,  grain  i. 
Tinct.  Aurantii,  drachm  i. 
Aq.,  ounce  i. 

M.  et  fiat  Mist. 

Dose,  one  drop  for  each  year  of  the  child's  age.  Administer 
it  every  hour  in  the  late  afternoon,  or  until  the  pupil  is 
dilated  at  bedtime,  and  give  a  dose  or  two  during  the 
night,  should  the  pupil  begin  to  contract.  The  object  of 
this  method  is  to  get  the  patient  so  thoroughly  imder  the 
influence  of  the  drug,  that  the  pupil  remains  dilated  whilst 
the  child  is  asleep.  Antipyrin  in  two-grain  doses  may 
also  be  tried.  Two  doses  should  be  given  at  intervals  of 
an  hour,  the  last  being  taken  just  before  the  patient  goes 
to  bed  with  an  empty  bladder.  The  drug  has  been  greatly 
extolled,  but  I  have  never  obtained  any  satisfactory  results 
from  its  use.  Astringent  injections  of  a  1  per  cent,  solu- 
tion of  alum,  tannin,  or  a  1  per  1000  solution  of  nitrate  of 
silver,  may  also  be  tried  in  very  obstinate  cases.  Three 
or  four  suppositories  daily,  each  containing  \  grain  of  nux 
vomica,  are  also  said  to  be  serviceable  ;  and  Von  Tienhoven 
recommends  that  the  foot  of  the  bed  should  be  raised  to  an 
angle  of  45°. 


CHAPTER  XXIV 
SURGICAL  AFFECTIONS  OF  THE  TESTICLE 


TUBERCLE   OF  THE  TESTICLE 


59 


Lloyd,  in  his  work  on  scrofula,  published  in  1821,  was 
the  first  to  refer  to  tubercle  of  the  testis  occurring  in  a 
child.  The  affection  is  rather  a  rare  one ;  but  Demme's 
statistics,  which  give  it  as  sixteen  times  in  1,932  cases, 
appear  to  be  more  correct  than  Jullien  s,  who  only  noticed 
it  sixteen  times  in  5,566  tubercular  children.  For  several 
years  past  one  or  two  cases  have  annually  come  under  my 
notice  at  the  Victoria  Hospital  for  Children. 

etiology. — Tuberculous  testis  affects  children  of  all 
ages,  and  it  has  even  been  found  to  be  congenital.  One 
gland  is,  as  a  rule,  infected,  and  a  definite  history  of  injury 
can  often  be  obtained.  The  disease  may  be  primary,  but 
it  is  more  often  seen  as  a  secondary  affection  in  the  course 
of  general  tuberculosis. 

Symptoms. — The  disease  presents  certain  differences 
in  the  course  which  it  runs  from  the  similar  affection  in 
adults,  due  no  doubt  to  the  fact  that  the  gland  in  children 
is  not  functional,  and  is  therefore  of  far  less  importance 
than  it  is  in  later  years.  The  onset  of  the  inflammation 
is  often  so  insidious  that  the  mother  only  accidentally  dis- 
covers that  the  child  has  a  swollen  testicle.  The  gland, 
on  examination,  is  then  found  to  be  larger  than  usual,  and 
to   present   a  hard  mass,  with  a  more  or  less   irregular 

475 


47^      THE    SURGICAL    DISEASES    OF    CHILDREN 

outline.  This  mass  is  situated  either  in  the  epididymis  or 
in  the  body  of  the  testicle.  The  gland  is  not  tender,  and 
usually  there  is  no  hydrocele.  It  may  occur  in  children 
who  otherwise  appear  to  be  in  such  good  health  as  to 
make  one  doubt  the  correctness  of  one's  diagnosis. 

The  affection  sometimes  begins  with  more  acute  symp- 
toms. The  skin  of  the  scrotum  becomes  tense,  slightly 
oedematous,  somewhat  reddened,  and  a  hydrocele  may  be 
formed.  After  a  few  days  these  symptoms  subside,  and 
an  enlarged  and  tender  gland  or  a  knobby  epididymis  can 
be  felt  within  the  scrotum. 

Prognosis. — The  prognosis  in  cases  of  simple  tuber- 
culous infection  of  the  testis  is  good.  The  swelling  usually 
remains  stationary  for  a  longer  or  shorter  period.  It  then 
slowly  diminishes,  and  finally  disappears  completely.  This 
disappearance  may  be  so  complete  that  the  testicle  atro- 
phies at  the  same  time,  and  the  child  becomes  monorchous. 
The  result  is  far  otherwise  when  the  infection  has  been 
a  mixed  one ;  that  is  to  say,  where  other  than  tubercle 
bacilli  alone  are  deposited  in  the  gland.  An  abscess  is 
then  produced  which  opens  through  the  scrotum,  leaving 
a  fistulous  tract.  Hernia  testis  is  rare,  but  the  neigh- 
bouring glands  are  early  affected.  These  suppurating 
cases  are  often  accompanied  by  tuberculous  dactylitis,  in- 
sidious spinal  caries,  or  manifestations  of  visceral  tubercle. 
The  vas,  vesiculae,  and  bladder  are  only  very  rarely  in- 
volved. Mr.  Bennett's  interesting  paper  on  "  Tubercular 
Disease  of  the  Testicle  "  59  as  a  local  affection  shows  that  in 
some  cases  the  vertebral  column  is  implicated  in  the  tuber- 
culous inflammation  which  has  commenced  in  one  testicle, 
even  before  the  disease  has  spread  to  the  seminal  vesicles 
of  the  same  side.  The  dissemination  does  not  appear  to 
take  place  until  the  original  focus  of  the  disease  has  begun 
to  undergo  degenerative  changes,  and  the  general  health 


SURGICAL    AFFECTIONS    OF    THE    TESTICLE      4/7 

does  not  become  affected  until  some  time  after  the  forma- 
tion of  an  abscess. 

Diagnosis. — There  is  usually  but  little  difficulty  in 
making  a  diagnosis,  but  care  must  be  taken  not  to  mis- 
take  tuberculous  disease  for  syphilis,  sarcoma,  or  dermoid 
cysts.  A  tuberculous  testis  cannot  always  be  differenti- 
ated from  a  syphilitic  one.  In  syphilis,  both  the  glands 
are  generally  involved  ;  in  tubercle,  only  one.  Syphilis 
may  transform  the  testicle  into  a  hard  and  painless  mass, 
the  epididymis  remaining  unaltered ;  whilst  in  tubercle 
the  gland  is  usually  tender  and  the  epididymis  is  affected. 
In  syphilis,  too,  there  is  often  other  evidence  of  the  inherited 
disease ;  and,  in  the  earlier  stages,  there  is  a  rapid  and 
marked  improvement  when  grey  powder  is  administered. 
Sarcoma  of  the  testis  is  rare  in  children ;  it  grows  more 
rapidly,  is.much  less  circumscribed,  and  shows  less  tendency 
to  suppurate.  Dermoid  cysts  are  so  rare  that  they  need 
only  be  mentioned. 

Treatment. — The  treatment  in  all  simple  cases,  where 
there  is  no  tendency  to  suppurate,  should  be  purely 
palliative.  Fresh  air,  cream  or  cod-liver  oil,  good  food 
and  plenty  of  sleep,  with  a  light  suspensory  bandage  and 
the  inunction  of  blue  ointment,  are  generally  sufficient. 
Care  should  be  exercised,  even  in  those  cases  which  appear 
the  most  harmless ;  for  it  should  be  remembered  that 
tubercle  bacilli  are  present  in  the  gland,  and  that  they 
may,  at  any  time,  and  most  insidiously,  infect  the  bones 
and  serous  membranes,  peritoneal,  pleural  or  meningeal. 

The  testicle  should  be  removed  at  once  if  there  is 
the  slightest  evidence  of  dissemination.  It  should  also 
be  removed,  and  with  it  the  infected  skin,  in  all  cases  of 
extensive  disorganisation  of  the  gland  which  has  been 
allowed  to  proceed  as  far  as  the  formation  of  sinuses. 


47^      THE    SURGICAL    DISEASES    OF    CHILDREN 

TUBERCULOUS  EPIDIDYMITIS. 

Chronic  inflammation  of  the  epididymis  is  by  no  means 
rare  in  children  who  have  other  manifestations  of  tubercle. 
It  occurs  as  an  indolent  swelling,  which  gradually  in- 
creases, suppurates,  and  may  burst,  leaving  fistulous  tracts. 
Jullien,  who  has  paid  much  attention  to  this  form  of 
disease,  says  that  he  has  never  seen  it  in  a  case  of  un- 
descended testis,  and  Grerster  maintains  that  it  is  embolic 
in  origin.  The  prognosis  is  good,  though  death  sometimes 
takes  places  as  a  result  of  general  tuberculosis. 

Treatment. — The  treatment  is  the  same  as  for  tuber- 
culous disease  of  the  testicle  itself.  Three  or  four  drops 
of  camphorated  naphthol  may  be  injected  into  the  sub- 
stance of  the  swelling  if  it  be  seen  before  suppuration 
has  taken  place ;  but  if  fistulse  are  present,  it  is  better  to 
excise  the  whole  testis. 

ABSCESS   OF  THE  TESTIS.60 

Mr.  Sheild  quotes  two  cases  of  simple  suppuration 
occurring  in  the  testicles  of  infants.  They  are  of  un- 
common occurrence,  and  I  have  never  seen  a  case.  They 
are  to  be  treated  by  the  ordinary  method  of  early  incision. 

Displaced  Testis. 

A  testicle  may  be  displaced  either  from  defective  action 
of  the  gubernaculum  testis  when  it  does  not  lie  in  its 
proper  position  in  the  scrotum,  or  it  may  be  displaced 
owing  to  irregular  action  of  the  muscle,  in  which  case  the 
testicle  may  not  be  situated  in  the  scrotum  at  all.  The 
gland  in  cases  of  retained  testis  may  lie  within  the  abdo- 
men, in  the  inguinal  canal,  or  at  the  top  of  the  scrotum. 
In  cases  of  ectopic  testicle  the  organ  may  lie  either  in  the 
groin  or  in  the  perineum,  for  the  gubernaculum  testis  has 


SURGICAL   AFFECTIONS    OF    THE    TESTICLE      479 

attachments  in  the  perineum  as  well  as  in  Scarpa's  tri- 
angle. Ectopia  perinealis  is  the  commoner  form.  It  is 
either  scroto-femoral  when  it  occupies  the  groove  between 
the  scrotnm  and  the  thigh,  or  it  is  perineal  when  it  lies 
behind  the  scrotum  near  the  middle  line  and  at  a  varying 
distance  in  front  of  the  anus. 

Diagnosis. — There  is  no  difficulty  in  recognising  that 
one  testicle  is  absent  from  the  scrotum,  though  the  defect 
is  often  masked  by  the  presence  of  a  hernia  or  of  a  hydro- 
cele. It  is  more  likely  to  be  overlooked  than  to  be  mis- 
taken for  any  other  condition.  The  scrotum  is  sometimes 
badly  developed  upon  the  affected  side  in  cases  of  an  un- 
descended or  of  an  ectopic  testis. 

Ectopia  femoralis  may  be  mistaken  for  an  enlarged 
lymphatic  gland,  for  only  a  few  years  since  such  a  gland 
was  sent  to  me,  removed  from  the  groin,  as  was  supposed, 
for  tuberculous  enlargement.  Examination,  however, 
showed  that  it  was  a  healthy  and  functionally  active 
testis. 

^Etiology.— Displaced  testes  are  so  rarely  functional, 
that  it  is  a  qttestion  whether  the  displacement  and  the 
Want  of  function  are  not  both  due  to  deficiency  in  the 
spermatic  artery,  rather  than  that  they  are  correlated  as 
cause  and  effect.    The  exact  setiology,  however,  is  unknown. 

Treatment. — In  cases  of  inguinal  hernia,  complicated 
with  retention  of  the  testis,  the  rupture  is  generally  found 
below  or  on  one  side  of  the  gland.  The  radical  operation 
for  the  cure  of  the  hernia  must  be  performed  in  such 
cases  in  the  manner  already  described  (p.  417).  The  testis 
may  at  the  same  time  be  brought  down  into  the  scrotum 
as  far  as  the  cord  will  allow,  and  sutures  should  be  passed 
through  the  pillars  of  the  ring.  The  sutures  are  generally 
sufficient  to  prevent  the  reascent  of  the  testicle,  but  it  is 
sometimes  necessary  to  still  further  secure  it  by  means 


480      THE    SURGICAL    DISEASES    OF    CHILDREN 

of  an  aseptic  silk  ligature  passed  through  the  gland  and 
the  skin  at  the  base  of  the  scrotum.  This  method  of 
orchidopexy,  as  it  is  termed,  has  recently  been  the  subject 
of  keen  debate  amongst  the  surgeons  in  Paris,  who  are  by 
no  means  unanimously  in  its  favour.  The  operation  should 
be  done  early  if  the  rupture  is  large,  if  it  is  difficult  to 
keep  up,  or  if  from  any  cause  the  wearing  of  a  truss  is 
painful  or  unsatisfactory.  It  should  never  be  deferred 
until  the  child  is  more  than  five  years  of  age,  for  in  such 
cases  there  is  an  arrest  of  the  normal  growth  of  the  gland. 
A  testicle  lying  in  the  perineum  is  often  only  held  in 
place  by  a  band  of  fibres  which  may  be  attached  either 
to  the  tuberosity  of  the  ischium,  to  the  external  sphincter 
of  the  anus,  or  to  the  skin.  The  subcutaneous  division  of 
this  band  occasionally  allows  the  testicle  to  be  replaced 
in  the  scrotum.  When  this  fails,  the  simple  operation 
recommended  by  Mr.  Bilton  Pollard  may  be  employed, 
even  when  the  scrotum  is  badly  developed.  The  testicle 
is  first  exposed,  and  is  raised  with  its  coverings,  including 
the  cremaster  muscle,  and  turned  upwards  as  far  as  the 
external  abdominal  ring.  An  incision  is  then  made  in  the 
lower  part  of  the  scrotum,  and  a  bed  is  formed  for  the 
testicle  amongst  the  connective  tissue.  A  pair  of  sinus 
forceps  is  thrust  up  from  the  wound  in  the  scrotum 
through  the  cellular  tissue  to  the  top  of  the  first  incision, 
close  to  the  external  abdominal  wound.  A  track  is  made 
by  separating  the  blades  of  the  forceps,  and  the  testicle  is 
pushed  along  it  as  gently  as  possible  into  its  new  bed. 
Both  wounds  are  then  closed,  and  they  should  heal  by  first 
intention. 

MALIGNANT  TUMOURS   OF  THE  TESTICLE. 

Carcinomata  are  of  less  frequent  occurrence  than  sarco- 
mata.     They  are  usually  congenital,  and  as  they  run  a 


SURGICAL    AFFECTIONS    OF    THE    TESTICLE    48 1 

rapid  course,  they  are  only  seen  in  the  youngest  children. 
Sarcomata  occur  in  older  children,  and  their  origin  is  some- 
times referred  to  an  injury  to  the  testicle. 

Symptoms.- — The  tumour  primarily  involves  the  epi- 
didymis or  the  body  of  the  testis,  and  is  often  undergoing 
cystic  degeneration.  It  is  generally  smooth,  heavy,  and 
hard,  but  its  shape  and  even  its  existence  may  be  masked 
by  the  presence  of  a  hydrocele  or  a  hsematocele.  It  is 
painless,  and  testicular  sensation  is  lost  early. 

Diagnosis. — The  affection  is  most  likely  to  be  mistaken 
for  tubercle  or  syphilis,  but  the  rapid  increase  in  its  size 
will  soon  point  out  its  true  nature. 

Prognosis. — The  lumbar  glands  may  become  affected, 
and  I  have  seen  a  diffuse  sarcomatous  infiltration  of  the 
entire  peritoneum  spreading  from  the  epididymis  up  the 
spermatic  cord  without  any  infiltration  of  the  glands. 

Treatment. — Early  removal  of  the  affected  testis  is 
imperative.  The  prognosis  is  bad,  for  secondary  deposits 
nearly  always  develop. 

Innocent  tumours  of  the  testicle  in  childhood  are  rare. 
There  are  a  few  cases  of  true  enchondroma  recorded. 


TORSION   OF  THE   SPERMATIC  CORD.61 

Nicoladoni,  in  1885,  first  called  attention  to  a  remark- 
able accident  in  which  the  testis  becomes  strangulated 
owing  to  twisting  of  the  spermatic  cord  up  to  or  beyond  an 
angle  of  180°.  Mr.  Bryant,  Mr.  Gifford  Nash,  Mr.  Edmund 
Owen,  and  Dr.  R.  W.  Johnson  have  recently  published  cases 
in  which  such  an  accident  has  occurred.  I  am  particularly 
indebted  to  Mr.  Bryant  for  the  readiness  with  which  he 
placed  at  my  disposal  the  block  (fig.  5G)  representing  the 
appearances  observed  in  the  case  which  he  published  in 
the  75th  volume  of  the  Medico-C/u'r.  Trans. 

1  1 


482      THE    SURGICAL    DISEASES    OF    CHILDREN 

iEtiology. — The  condition  may  occur  in  a  testis  lying 
in  the  scrotum,  but  it  is  more  often  seen  in  an  undescended 
or  partially  descended  testis,  and  it  is  met  with  at  all 
ages,  though  it  is  most  common  in  young  adults.  The 
predisposing  cause  is  the  freedom  with  which  the  testicle 
is  suspended  in  the  scrotum,  associated,  Dr.  Lauenstein 
thinks,  with  a  flat  form  of  testis,  with  division  of  the 
cord  into  two  sections,  and  with  abnormal  conditions  of 


Fig.  56. — Torsion  of  the  spermatic  cord. 
[Copied,  by  Mr.  Bryant's  permission,  from  the  "  Transactions  of  the  Royal  Medico- 

Chirurgical  Society."'] 

the  tunica  vaginalis,  leading  to  an  undue  widening  of  the 
constituents  of  the  spermatic  cord.  The  exciting  causes 
are  unknown,  for  the  accident  has  sometimes  occurred  after 
such  prolonged  jarring  as  would  be  caused  by  a  long 
bicycle  ride,  by  boxing  or  by  jumping  ;  but  in  other  cases 
no  cause  has  been  assigned. 

Morbid  Anatomy. — The  tunica  vaginalis  is  tense  and 
inflamed,   and  it  usually  contains   fluid.     The  spermatic 


SURGICAL    AFFECTIONS    OF    THE    TESTICLE    483 

cord  is  twisted  upon  its  axis  either  once  or  more  than 
once,  and  usually  in  a  lsevo-rotatory  direction.  It  is 
often  gorged  with  blood,  and  the  pampiniform  plexus  may 
contain  thrombi.  The  testis  or  the  epididymis,  or  both, 
may  be  acutely  inflamed,  and,  if  the  strangulation  has 
been  left  for  some  time,  the  inflamed  part  may  become 
gangrenous  and  exfoliate,  or  it  may  atrophy.  Miflet  has 
endeavoured  to  explain  this  by  showing  that  the 
branches  of  the  spermatic  artery  supplying  the  testis 
itself  are  terminal  arteries,  whilst  those  which  supply  the 
epididymis  anastomose  with  the  artery  of  the  vas.  Inter- 
ference with  the  blood-flow  in  the  terminal  branches  of 
the  artery  is  therefore  followed  by  hsemorrhagic  infarction 
of  the  superficial  layer  of  the  testicle,  whilst  the  epidi- 
dymis remains  comparatively  free.  This  explanation, 
however,  does  not  hold  good  for  those  cases  in  which  the 
epididymis  is  alone  or  chiefly  affected. 

Symptoms. — The  symptoms  are  a  painful  swelling, 
which  appears  suddenly  in  the  groin  or  scrotum,  dull  on 
percussion,  irreducible,  and  without  any  impulse  on  cough- 
ing. The  consistence  of  the  swelling  is  firm  and  doughy. 
The  scrotum  may  be  red  and  oedematous.  The  abdomen 
in  some  instances  is  distended  and  tender.  There  is  often 
some  rise  of  temperature,  with  a  quickened  pulse,  and  some 
symptoms  of  shock.  Sickness  is  a  very  constant  symptom, 
and  constipation  is  frequent,  though  it  is  not  absolute. 

Diagnosis. — It  is  not  surprising  that  with  such  a 
history  and  with  such  symptoms  the  greater  number  of 
cases  in  which  this  accident  has  happened  have  been 
diagnosed  as  instances  of  strangulated  hernia,  though  it 
is  possible  to  assume  that  it  was  due  to  gonorrhceal  or 
traumatic  inflammation  of  the  testis  and  epididymis. 

Differential  Diagnosis. — A  diagnosis  between  twisting 
of  the  spermatic  cord,  a  strangulated  hernia,  and  a  bubo, 


484      THE    SURGICAL    DISEASES    OF    CHILDREN 

has  to  be  made.  There  is  more  shock  in  cases  of  hernia, 
the  external  ring  contains  a  tumour,  and  the  spermatic 
cord  is  masked  by  the  swelling.  A  bubo,  unless  a  testicle 
is  absent  from  the  scrotum,  is  recognised  by  the  absence  of 
shock,  the  patent  abdominal  canal  and  the  normal  cord. 

Prognosis. — The  result  depends  upon  the  severity  of 
the  torsion.  If  the  cord  is  only  slightly  twisted,  it  may 
recover  itself,  the  testis  remaining  natural  in  size,  but 
inverted,  i.e.  the  epididymis  may  lie  in  front  of  the  testis. 
In  more  severe  cases,  when  the  vascular  supply  is  inter- 
fered with  and  infarction  has  taken  place,  the  testis 
becomes  swollen,  congested,  and  eventually  atrophies. 
Gangrene  of  the  organ  quickly  ensues  in  the  most  severe 
cases,  when  the  twisting  has  been  extensive. 

Treatment.— The  spermatic  cord  and  testis  must  be 
exposed  as  soon  as  the  condition  is  recognised,  for  taxis 
is  clearly  contra-indicated.  The  cord  should  be  untwisted 
if  it  appears  reasonable  to  suppose  that  the  inflammatory 
conditions  have  not  already  advanced  too  far  to  save  the 
organ.  A  retained  testicle,  or  one  which  is  very  much 
swollen  or  discoloured,  is  best  removed,  for  it  will  either 
atrophy  or  die. 

DERMOID  CYST   OF  THE  TESTIS. 

Dermoid  cysts  of  the  testicle  are  occasionally  met  with. 
A  few  years  since  I  showed  one  which  had  been  removed 
from  a  child  four  years  old,  in  whom  it  had  been 
observed  for  three  years. 

Morbid  Anatomy.— Examination  of  such  a  tumour 
shows  cysts  lined  with  slightly  altered  epidermis,  from 
which  hairs  may  spring.  The  solid  parts  of  the  tumour 
consist  of  dense  fibrous  tissue  with  fat,  and  eyots  of  car- 
tilage may  also  be  present. 


SURGICAL    AFFECTIONS    OF    THE    TESTICLE    485 

Symptoms. — The  tumour  iu  my  case  was  smooth, 
ovoid,  regular  in  outline,  and  heavy  ;  there  was  a  sense  of 
fluctuation  in  parts,  but  there  was  nowhere  any  trans- 
lucency.  No  nodules  could  be  felt  on  palpation,  but  the 
fluctuating  parts  were  less  resistant  than  the  rest  of  the 
gland.  The  testicular  substance  could  not  be  felt,  and 
the  epididymis  was  imperceptible.  The  tumour  was  in- 
creasing slowly  in  size.  The  scrotum  appeared  to  be 
normal,  and  was  free  from  any  scar. 

Treatment. — The  only  treatment  for  these  tumours  is 
removal. 

HYDROCELE. 62 
Varieties. — Hydrocele  is  of  very  common  occurrence  in 
children  of  all  ages.  It  is  either  congenital  or  acquired. 
The  acquired  form  is  either  single,  and  is  a  hydrocele  of 
the  funicular  process  shut  off  above  and  below,  or  it  is 
a  hydrocele  of  the  tunica  vaginalis.  Double  acquired 
hydrocele  is  sometimes  met  with  after  acute  diseases,  and 
is  most  frequently  seen  after  scarlatina.  The  sac  is 
usually  simple,  but  it  may  be  multilocular.  Hydrocele 
of  the  testicle  in  children  is  in  reality  a  chronic  serous 
periorchitis,  and  may  begin  acutely. 

Acute  Hydrocele. 
The  acute  cases  are  generally  seen  in  children  of  fifteen 
days  to  six  weeks  old.  The  hydrocele  is  associated  with 
an  erythematous  condition  of  the  skin  of  the  genitals,  and 
is  often  associated  with  digestive  disturbances.  It  is 
limited  to  one  side,  and  is  very  tense  and  elastic.  It  lasts 
from  two  to  six  weeks,  and  is  amenable  to  treatment,  for 
it  disappears  with  the  skin  eruption.  The  treatment, 
therefore,  consists  in  correcting  the  digestive  disturbance, 
and  applying  vaseline  or  boric  acid  in  powder  to  the 
affected  parts. 


486      THE    SURGICAL    DISEASES    OF    CHILDREN 

Chronic  Hydrocele. 

The  causes  of  chronic  hydrocele  are  not  yet  known. 
The  congenital  form  is  said  to  be  due  to  the  arrest  of 
those  developmental  changes,  cutting  off  the  connection 
between  the  peritoneum  and  the  tunica  vaginalis,  which 
ought  to  be  completed  before  birth ;  and  it  is  for  this 
reason  that  such  hydroceles  often  undergo  spontaneous 
cure.  An  acquired  hydrocele  is  often  attributed  to  an 
injury,  to  urethritis,  to  balanitis  or  to  phimosis  ;  but  we 
are  ignorant  as  to  the  manner  in  which  these  conditions 
lead  to  a  collection  of  fluid  in  the  tunica  vaginalis. 

Symptoms. — The  symptoms  are  similar  to  those  pre- 
sented by  an  adult.  There  is  a  tense,  elastic  swelling  in 
the  scrotum,  which  is  translucent.  The  swelling  in  some 
congenital  cases  can  be  reduced  in  size  by  returning  the 
fluid  it  contains  into  the  abdominal  cavity.  The  testis  is 
generally  situated  behind  the  sac,  but  it  may  be  in  front ; 
it  may  be  retained,  or  it  may  not  have  descended  to  the 
bottom  of  the  scrotum.  A  hernia  may  complicate  the 
hydrocele  either  by  passing  directly  into  the  sac,  or  by 
invaginating  its  upper  wall.  A  hydrocele  of  the  cord  is  a 
circumscribed  tumour  presenting  the  same  general  cha- 
racters as  that  described  above  ;  but  it  is  situated  at,  or 
actually  within,  the  external  abdominal  ring,  and  it  is 
therefore  more  likely  to  be  mistaken  for  a  hernia. 

Diagnosis. — Hydroceles  have  to  be  distinguished  from 
hernise,  from  cysts  of  the  spermatic  cord,  and  from  retained 
testis.  The  translucency  of  a  hydrocele  will  at  once  dis- 
tinguish it  from  a  hernia  or  a  retained  testis,  whilst  the 
presence  of  a  single  cyst  will  distinguish  a  hydrocele  of 
the  cord  from  a  multilocular  cystic  tumour. 

Prognosis  and  Treatment.  —  The  prognosis  of  all 
forms  of  hydrocele  in  children  is  good ;  and  if  the  hydro- 


SURGICAL   AFFECTIONS    OF    THE    TESTICLE    487 

cele  does  not  disappear  after  a  few  months,  it  may  be 
punctured  with  a  very  fine  trocar  and  canula.  All  the 
fluid  should  be  drawn  off,  and  the  puncture  should  be 
closed  with  a  piece  of  absorbent  wool  soaked  in  collodion. 
In  the  congenital  forms,  where  there  is  a  wide  aperture 
of  communication  with  the  peritoneum,  a  woollen  truss 
(p.  413)  may  be  worn  for  a  few  months,  to  prevent  the 
formation  of  a  hernia  whilst  the  developmental  changes 
are  being  completed. 

When  the  hydrocele  refills  after  puncture,  it  may  be  in- 
jected with  a  1  in  5000  solution  of  perchloride  of  mercury, 
for  the  hydrocele  fluid  is  rich  in  globulins,  which  are 
precipitated  by  the  mercuric  salt.  I  have  recently  been 
treating  troublesome  cases  which  refill  in  spite  of  tapping 
and  injections,  by  laying  open  the  scrotum  and  dissecting 
out  the  sac,  ligaturing  its  neck,  if  necessary,  with  aseptic 
silk.  The  wound  on  every  occasion  has  healed  by  first 
intention,  and  the  results  have  appeared  to  be  so  satis- 
factory that  I  propose  to  continue  it. 

DISEASES  OF   THE  FEMALE  GENERATIVE 

ORGANS. 

Ovarian  Tumours.63 

Varieties.  —  Ovarian  tumours  occur  in  quite  young 
children,  and  they  are  occasionally  congenital.  They  may 
be  classified  as  innocent  and  malignant.  The  innocent 
tumours  are  either  cystic,  fibrous,  or  dermoid.  The  malig- 
nant tumours  are  either  simple  or  cystic  sarcomata,  or, 
more  rarely,  carcinomata. 

Diagnosis. — Ovarian  tumours  in  young  children  may 
be  mistaken  for  sarcoma  of  the  kidney,  hydatids  of  the 
liver,  congenital  hydronephrosis,  cysts  of  the  mesentery,  or 
even  for  tuberculous   peritonitis.     Precocious  pregnancy 


488      THE    SURGICAL    DISEASES    OF    CHILDREN 

should  always  be  excluded  in  older  children.  The  diag- 
nosis must  be  made  by  a  physical  examination  conducted 
bimanually  through  the  rectum  and  abdomen — a  proceed- 
ing which  is  greatly  facilitated  by  the  administration  of 
an  anaesthetic.  The  exact  seat  and  nature  of  the  tumour 
can  often  be  cleared  up  only  by  an  exploratory  incision. 
Tuberculosis  of  the  ovaries  and  Fallopian  tubes  may  some- 
times be  recognised  by  this  method. 

Treatment. — The  first  ovariotomy  in  a  child  was  per- 
formed by  Mr.  Bryant ;  but  there  are  now  many  cases  on 
record.  The  operation  for  innocent  tumours  is  attended  by 
satisfactory  results,  unless  the  adhesions  are  very  extensive, 
or  there  are  intimate  attachments  to  the  viscera.  The 
mortality  after  operations  for  malignant  tumours  is  so  high 
that  it  is  doubtful  whether  the  operation  is  justifiable. 

Pyosalpinx. 
A  few  cases  are  recorded  in  which  one  or  both  Fal- 
lopian tubes  in  young  girls  have  been  found  to  be  dis- 
tended with  pus.  The  condition  is  usually  associated 
with  general  tuberculosis,  and  as  yet  has  only  a  patholo- 
gical interest. 

Sarcoma  of  the  Vagina. 
This   occurs  occasionally   in   children  of   three  to  four 
years  old  as  a  primary  affection.     The  growth  eventually 
protrudes  from  the  vulva,  and  readily  recurs  after  removal. 

Vulvitis. 

Vulvitis  is  more  common  in  children  than  vulvovagi- 
nitis, for  the  vagina  and  the  glands  in  its  neighbourhood 
are  not  yet  functional,  and  the  inflammation  is  therefore 
less  likely  to  spread. 

etiology. — The  ordinary  causes  are  local  inflammatory 
conditions  occurring  in  neglected  and  tuberculous  children  ; 


SURGICAL   AFFECTIONS    OF    THE    TESTICLE     489 

but  it  is  sometimes  seen  in  connection  with  the  exanthe- 
mata, as  has  been  already  described  (p.  21). 

Treatment. — The  treatment  consists  in  the  removal  of 
any  causes  of  local  irritation,  such  as  thread-worms,  and 
it  then  yields  readily  to  the  ordinary  antiseptic  applica- 
tions, with  cod-liver  oil  and  a  little  grey  powder  in  the 
more  debilitated  children.  Dr.  Amand  Routh  suggests 
the  use  of  a  lotion  consisting  of  warm  milk  and  water,  to 
each  pint  of  which  a  teaspoonful  of  borax  and  a  teaspoon- 
ful  of  liquor  plumbi  subacetatis  have  been  added.  The 
lotion  should  be  applied  several  times  a  day  by  making 
the  child  sit  in  a  basin  or  bath  containing  it.  The  parts 
should  be  well  dried,  and  a  piece  of  lint  soaked  in  the 
lotion  should  be  kept  over  them. 

VULVO-  VAGINITIS. 

Vulvo-vaginitis  also  occurs  in  children,  but  it  is  usually 
the  result  of  gonorrhoeal  infection.  An  epidemic  of  the 
gonorrhceal  form  has  lately  been  traced  to  the  indiscri- 
minate use  of  a  thermometer  introduced  into  the  vagina 
of  several  children  in  succession  and  without  proper 
cleansing. 

The  Treatment  is  the  same  as  for  cases  of  vulvitis ; 
but  if  the  discharge  is  very  irritating,  Dr.  Routh  advises 
that  a  solution  containing  a  scruple  of  nitrate  of  silver  in 
each  ounce  of  water  should  be  painted  over  the  inflamed 
area,  which  should  then  be  covered  with  a  layer  of  oint- 
ment made  by  mixing  thirty  minims  of  extract  of  hama- 
melis  with  an  ounce  of  vaseline. 

Adherent  Labia  Minora. 
Children  are  often  brought  to  the  surgeon  with  a  slight 
adhesion  of   the  labia   minora.     The   two  labia   must  be 
separated  with  a  probe,  and  a  pledget  of  oiled  lint  should 
be  kept  in  the  vaginal  orifice  for  twenty-four  hours. 


CHAPTER  XXV 
DISEASES  OF  BLOODVESSELS   AND   KEV1 

ANEURYSMS.64 

Aneurysms  are  rarely  met  with  in  children,  but  traumatic 
and  intracranial  aneurysms  are  more  frequent  than  the 
spontaneous  forms.  Traumatic  aneurysms  may  occur  in 
any  part  of  the  body,  though  they  are  most  frequent  at 
the  wrist,  on  the  dorsum  of  the  foot,  and  in  the  posterior 
tibial  artery.  The  only  one  which  I  have  seen  came 
under  my  care  when  I  was  acting  as  ophthalmic  house- 
surgeon  at  St.  Bartholomew's  Hospital.  It  was  intra- 
orbital, and  resulted  from  a  gunshot  wound,  in  a  young 
adult.  Furious  hsemorrhage  from  the  nose  took  place, 
which  was  permanently  controlled  by  ligature  of  the 
common  carotid  artery.  Spontaneous  aneurysms  are  either 
primary  or  secondary.  The  primary  forms  are  extremely 
rare,  and  the  recorded  cases  have  been  carefully  tabulated 
by  Mr.  R.  W.  Parker  in  the  67th  volume  of  the  Transac- 
tions of  the  Royal  Medico-Chirurgical  Society,  and  more 
recently  by  Prof.  Keen.64  The  secondary  aneurysms  are 
embolic  in  origin,  and  are  usually  associated  with  valvular 
disease  of  the  heart.  They  are  often  intracranial,  and  may 
be  multiple. 

Treatment. — The  treatment  does  not  differ  from  the 
treatment  of  similar  conditions  in  adults.  The  traumatic 
forms,  if  they  are  accessible,  must  be  cut  down  upon,  the 

490 


DISEASES    OF    BLOODVESSELS    AND    N/EVI    49 1 

• 

artery  ligatured  upon  either  side  with  aseptic  silk,  the 
sac  removed,  and  the  wound  should  be  made  to  heal  by 
first  intention.  The  spontaneous  aneurysms  may  first  be 
treated  by  pressure,  and  if  this  fails,  an  interval  of  several 
days  should  be  allowed  to  elapse  before  the  artery  is 
ligatured  by  the  Hunterian  method,  but  with  aseptic 
silk. 

NJSVI.64 

etiology. — Naevi  are  usually  innocent,  and  they  are 
often  purely  local.  Little  or  nothing  is  known  of  their 
cause,  except  that  they  may  be  hereditary,  and  are  perhaps 
the  result  of  congenital  trophic  neuroses.  Mr.  R.  W. 
Parker  believes  that  they  are  due  to  abnormal  conditions 
of  the  capillary  plexuses  which  surround  the  appendages 
of  the  skin,  especially  of  the  hair  follicles,  or  of  the 
vascular  loops  found  in  the  papillae  of  the  true  skin. 

They  occur  in  all  parts  of  the  body,  for  I  have  seen 
them  in  the  liver  and  in  the  membranes  of  the  brain ;  but 
only  those  which  grow  in  connection  with  the  skin  and 
mucous  membranes  at  the  orifices  of  the  body  can  be 
treated  by  surgical  means. 

Varieties. — Nsevi  are  either  vascular,  lymphatic,  or 
pigmented.  The  vascular  nsevi  are  either  capillary, 
cavernous,  or  arterial — the  lymphangiomata  forming  a 
separate  group.  The  pigmented  occur  as  hairy  moles,  or 
simply  as  pigmented  portions  of  skin  in  connection  with  a 
system  of  dilated  bloodvessels. 

The  "  capillary  "  nsevus  is  the  most  common  form  of 
vascular  nsevus.  It  is  a  small  and  bright  red  patch  in  its 
si  in  1  ilest  condition,  situated  upon  some  part  of  the  skin,  or 
upon  the  mucous  membranes  of  the  inner  canthus  of  the 
eye,  the  lip,  or  tongue.  This  form  of  nsevtis  is  sometimes 
multiple  ;  it  grows  rapidly  or  slowly,  or  it  may  disappear 


492     THE    SURGICAL    DISEASES    OF    CHILDREN 

entirely  during  the  first  year  of  life.     It  is  said  that  76 
per  cent,  of  these  nsevi  grow  upon  some  part  of  the  head. 

Treatment. — The  treatment  in  the  simplest  form  con- 
sists in  the  application  of  ethylate  of  sodium,  or,  as  Drs. 
Boing  and  Caesfield 64  have  each  recommended,  a  1  in  8 
solution  of  corrosive  sublimate  collodion  ;  though,  as  this 
is  usually  too  strong  an  application  for  young  children,  I 
use  a  1  in  12.  It  is  a  most  effective  remedy,  but  the  skin 
surrounding  the  nsevus  must  first  be  protected  by  a  layer 
of  simple  collodion,  which  should  be  allowed  to  dry  before 
the  sublimate  collodion  is  applied.  Two  or  three  coats  of 
the  collodion  are  applied,  and  are  left  on  for  ten  or  twelve 
days,  when  the  pellicle  falls  off,  leaving  an  ulcer  which 
soon  heals,  or  a  smooth  and  white  scar.  These  applica- 
tions are  only  serviceable  in  the  very  slightest  cases,  and 
fuming  nitric  acid  has  generally  to  be  applied  to  the 
ordinary  capillary  nsevi,  though  such  applications  cannot 
be  made  to  growths  near  the  eye.  The  skin  round  the 
nsevus  is  protected  by  painting  over  it  a  layer  of  olive  oil, 
and  the  nsevus  is  then  brushed  with  fuming  nitric  acid 
until  the  epithelium  is  destroyed.  It  is  covered  with  a 
layer  of  gauze,  cemented  over  the  sore  place  with  collodion 
if  the  nsevus  is  small,  or  a  wet  dressing  is  applied  if  the 
growth  is  so  large  that  there  is  likely  to  be  much  dis- 
charge. Capillary  nsevi  may  be  very  extensive  ;  they 
may  grow  rapidly  for  some  time,  and  may  then  become 
stationary.  They  sometimes  form  "  port- wine  stains,"  or 
pigmented  nsevi,  which  are  disfiguring,  but  which  are  not 
yet  amenable  to  any  form  of  treatment,  for  the  scar  left 
may  be  worse  than  the  original  mark. 

Subcutaneous  or  "  venous  "  nsevi  are  met  with  nearly  as 
often  as  the  capillary  forms.  They  are  soft  tumours  situ- 
ated beneath  the  skin,  and  they  often  have  a  capillary 
nsevus  immediately  above  them.     They  occur  in  any  part 


DISEASES    OF    BLOODVESSELS    AND    N.EVI     493 

of  the  body ;  they  may  be  multiple,  and  they  are  sometimes 
found  to  develop  beneath  a  capillary  naevus.  They  may 
attain  to  an  enormous  size,  when  they  may  take  the  form 
of  a  general  telangiectasis,  and  may  be  associated  with 
the  presence  of  a  rete  mirabile  in  place  of  some  of  the 
large  venous  trunks,  as  in  the  late  Mr.  Hulke's  case. 
They  are  soft  swellings  which  can  be  reduced  by  gentle 
and  sustained  pressure. 

Pathology. — These  nsevi  are  either  capillary  or  venous. 
The  capillary  form  consists  entirely  of  altered  capillaries, 
which  communicate  freely  one  with  another,  forming  large 
spaces.  The  venous  form  is  partly  produced  by  dilatation 
of  the  veins,  and  partly  by  dilatation  of  the  capillaries. 
They  undergo  many  secondary  changes  in  the  course  of 
their  growth,  for  they  may  become  converted  into  fibrous 
tissue,  they  may  undergo  cystic  and  fatty  change,  or  they 
even  become  sarcomatous.  Mr.  Stephen  Paget  has  shown 
that  some  of  the  less  well-defined  forms  may  be  cured 
spontaneously  by  a  process  of  indolent  ulceration,  com- 
mencing at  the  centre,  and  spreading  to  the  periphery. 
The  ulceration,  though  usually  slow  and  painless,  some- 
times runs  an  acute  course,  apparently  as  a  result  of 
thrombosis,  and  in  such  cases  sloughing  may  occur. 

Treatment. — There  is  no  doubt  that  in  a  healthy  child 
the  ideal  method  of  treatment  is  by  cleanly  dissecting  the 
tumour  away,  if  it  is  situated  in  any  part  except  the  face. 
The  capsule  should  not  be  opened,  for  the  nsevus  can  then 
usually  be  removed  without  much  loss  of  blood.  This 
method,  however,  is  frequently  impossible,  on  account  of 
the  size  or  position  of  the  nsevus,  and  electrolysis  then 
offers  the  best  substitute  for  it. 

The  treatment  of  nsevi  by  electrolysis  was  systematised 
in  this  country  by  the  late  Dr.  Steavenson,  and  has  been 
worked  out  by  Dr.  Lewis  Jones.     It  is  best  fitted  for  the 


494     THE    SURGICAL    DISEASES    OF    CHILDREN 

cure  of  subcutaneotis  nsevi,  which  can  sometimes  be  de- 
stroyed by  this  method  without  leaving  any  scar  except 
the  marks  made  by  the  entrance  of  the  needles.  It  has 
the  great  advantage  over  excision  and  the  application  of 
caustics,  of  being  painless,  but  it  has  the  disadvantage  of 
requiring  several  sittings  to  effect  a  cure. 

The  needles  employed  are  either  single  or  multiple,  and 
they  are  of  platinum,  for  use  both  at  the  positive  pole  and 
at  the  negative  pole  of  the  battery.  They  are  insulated, 
except  at  their  points,  and  they  must  be  thrust  into  the 
tissues  as  far  as  the  insulated  portion  before  the  current 
is  passed,  so  that  the  skin  may  remain  unaffected.  When 
it  is  essential  that  the  scarring  should  be  as  slight  as 
possible,  the  platinum  needles  connected  with  the  positive 
pole  are  put  into  the  naevus,  whilst  a  pad  moistened  with 
salt  solution  is  applied  to  some  other  part  of  the  body,  and 
attached  to  the  negative  pole. 

A  current  of  10-30  milliamperes  is  sufficient  for  delicate 
nsevi.  It  is  passed  for  five  minutes,  and  the  position  of 
the  needles  in  the  tumour  is  then  altered,  but  without 
withdrawing  their  points,  and  the  current  is  passed  for  a 
second  period  of  five  minutes.  Needles  from  both  poles 
may  be  passed  into  the  tumour  when  scarring  is  of  less 
consequence,  and  the  nsevi  are  large.  A  current  of  30-50 
milliamperes  may  be  employed  in  such  cases,  the  position 
of  the  needles  being  frequently  changed.  (An  ampere  is 
the  unit  of  current  strength  in  the  same  manner  that  an 
inch  is  the  unit  of  length.  It  is  roughly  the  current 
generated  by  a  single  Daniell's  (copper  sulphate)  cell  or 
volt  passing  through  the  resistance  of  one  ohm,  which  is  a 
column  of  mercury  one  square  millimetre  in  cross  section 
and  100  centimetres  in  length.  The  electrical  unit  em- 
ployed in  medicine  is  the  one-thousandth  part  of  an 
ampere  or  a  milliampere).     A  battery  of  Leclanche  (sal 


DISEASES    OF    BLOODVESSELS    AND    N.*:VI    495 

ammoniac)  cells  or  of  Stohrer's  (bichromate)  cells  is  gene- 
rally employed  to  generate  the  electricity  ;  whichever  is 
nsed  must  be  provided  with  a  galvanometer  graduated  in 
milliamperes,  so  that  the  surgeon  may  know  the  strength 
of  the  current  he  is  using. 

The  needles  having  been  introduced,  the  current  is 
slowly  raised  until  gas  is  evolved  round  the  needles  at 
both  poles.  The  current  must  be  shut  off  before  the 
needles  are  withdrawn,  and  any  slight  bleeding  which  may 
occur  from  the  site  of  the  positive  pole  is  easily  arrested 
by  the  application  of  a  pad  and  bandage. 

No  attempt  should  be  made  to  do  too  much  at  a  time, 
and  the  child  must  be  anaesthetised.  The  object  of  the 
operation  is  to  break  up  the  bloodvessels,  and  to  coagulate 
the  blood,  but  not  to  cause  necrosis  or  destruction  of  the 
skin.  The  method  is  a  useful  one,  and  by  it  a  large 
nsevus  may  often  be  converted  into  a  mass  of  fibrous 
tissue,  which  can  in  due  course  be  excised. 

In  very  many  cases,  however,  nsevi  are  beyond  the  reach 
of  surgery.  They  are  sometimes  very  troublesome  to  treat 
when  they  occur  near  the  inner  canthus  of  the  eye,  for  the 
scar  produced  in  curing  them  may  give  rise  to  ectropion, 
or  to  stillicidium  lachrymarum,  from  displacement  of  the 
punctum  ;  on  the  other  hand,  if  they  are  not  completely 
removed,  they  grow  again  with  astonishing  pertinacity. 

Akterio- Venous  Angiomata. 
These  are  frequently  congenital,  but  they  are  sometimes 
only  observed  after  an  injury.  They  may  occur  at  any 
part  of  the  body,  and  sometimes  involve  the  soft  tissues, 
and  even  the  bones,  so  extensively  as  to  render  their 
removal  an  impossibility.  Thrombosis  of  the  main  veins 
has  occurred  in  some  of  these  cases,  whilst  others  have 
been  attended  by  gangrene  of  the  soft  parts. 


496     THE    SURGICAL    DISEASES    OF    CHILDREN 

Arterial  Njevi. 

Arterial  nsevi  nearly  always  occur  upon  the  head, 
though  they  have  been  seen  upon  the  dorsum  of  the  foot, 
in  direct  connection  with  the  dorsalis  pedis  artery.  They 
may  form  a  small  pulsating  swelling,  communicating  with 
one  of  the  main  branches  of  the  temporal  artery,  or  more 
often  they  are  very  large  tumours,  occupying  the  greater 
part  of  one  side  of  the  skull — the  true  cirsoid  aneurysm,  or 
aneurysm  by  anasto7nosis.  They  are  occasionally  found  in 
the  orbit,  in  the  nasal  fossae,  and  amongst  the  deep  muscles 
of  the  neck ;  but  in  these  positions  they  cannot  be  treated 
surgically.  They  should,  if  possible,  be  starved  by  liga- 
turing the  main  trunks  of  the  arteries  ;  and  when  this  has 
been  done  effectually,  the  tumour  may  afterwards  be  re- 
moved at  leisure  and  without  much  loss  of  blood. 


BLOOD  TUMOURS   OF  THE   SCALP. C5 


iEtiology. — Prof.  Lannelongue  65  and  Dr.  Mastin  have 
called  attention  to  various  forms  of  blood  tumours  found  on 
the  scalps  of  children.  These  tumours  communicate  with 
the  superior  longitudinal  sinus.  They  are  sometimes  con- 
genital, and  sometimes  the  result  of  injuries.  The  trau- 
matic forms  appear  to  be  due  either  to  direct  injury  of  the 
sinus,  or  to  rupture  of  some  of  the  veins.  The  congenital 
tumours  are  true  angiomata,  accompanied  by  a  dilatation 
of  the  veins  connecting  the  intracranial  with  the  peri- 
cranial circulation,  and  communicating  with  a  dilated 
longitudinal  sinus.  They  are  often  associated  with  re- 
tarded ossification  of  the  cranial  bones. 

Symptoms. — A  soft,  irreducible  tumour,  with  the 
characters  of  a  subcutaneous  naevus  situated  upon  the 
scalp  near  the  middle  line,  but  differing  from  an  ordinary 


DISEASES    OF    BLOODVESSELS    AND    NvEVI    497 

nsevus  in  possessing  a  pedicle  which  passes  through  the 
sagittal  suture. 

Treatment. — Well-applied  pressure  appears  to  be  the 
most  satisfactory  treatment  in  the  traumatic  cases,  if  it  be 
commenced  as  soon  after  the  accident  as  possible ;  whilst 
in  the  congenital  cases  nothing  should  be  done  so  long  as 
the  tumour  is  small  and  stationary ;  but  if  it  is  increasing 
in  size,  and  there  appears  to  be  a  danger  of  its  rupture, 
the  pedicle  should  be  ligatured  and  the  tumour  removed. 

LYMPHANGIOMATA.6*5 

Varieties. — Lymphangiomata  exist  either  as  dilated 
vessels  forming  a  lymphangiectasis  or  as  lymphangioma. 
True  lymphangiomata  have  already  been  dealt  with  in 
that  form  which  occurs  as  macroglossia  or  macrocheilia 
(p.  266).  They  are  congenital  tumours,  formed  by  the 
distension  of  pre-existing  lymph  paths,  with  a  general 
hyperplasia  of  the  surrounding  tissue.  Cavernous  lym- 
phangiomata are  found  in  various  parts  of  the  body  either 
as  small  and  well-defined  vesicular  tumours,  or  as  diffuse 
growths  leading  to  a  condition  of  false  elephantiasis. 
These  tumours  are  often  congenital,  but  they  are  some- 
times said  to  bear  a  direct  relation  to  injuries.  Mr. 
Harold  Stiles,06  in  a  recent  and  interesting  paper,  has 
shown  that  a  cavernous  lymphangioma  growing  upon  the 
forearm  contained  a  considerable  quantity  of  unstriped 
muscular  tissue  in  its  substance.  Cavernous  lymphangio- 
mata may  undergo  cystic  degeneration  when  they  form 
cystic  hygroinata. 

Symptoms. — The  symptoms  of  a  cavernous  lymphan- 
gioma vary  with  the  character  of  the  growth  from  a  small 
vesicular  tumour  filled  with  a  clear  fluid,  which  cannot  be 
mistaken,  through  the  subcutaneous  form  which  may  be 
looked  upon  as  a  lipoma,  up  to  the  most  diffuse  form  which 

K   K 


49§     THE    SURGICAL    DISEASES    OF    CHILDREN 

enlarges  the  part  affected  to  a  condition  of  elephantiasis. 
The  circnmscribed  form  of  subcutaneous  lymphangioma  is 
most  often  seen  upon  the  shoulder,  either  in  the  supra- 
clavicular or  in  the  supraspinous  regions,  and  it  is  liable 
to  sudden  haemorrhages  into  its  substance. 


Fig.  57. — A  child,  aged  H  days,  with  cystic  lymphangioma  of  the  left  side 
of  the  face,  before  its  removal. 

Treatment. — The  treatment  of  lymphangiomata,  like 
that  of  the  angiomata  or  neevi,  consists  in  compression, 
electrolysis,  excision,  or,  if  the  surgeon  prefers  to  adopt  it, 
the  injection  of  iodine,  carbolic  acid,  or  dilute  solutions  of 
corrosive  sublimate. 


DISEASES    OF    BLOODVESSELS    AND    N/EVI    499 

Cystic  Hygroma. — These  tumours  form  an  extremely 
interesting  group  of  cases.  They  are  pathologically  cystic 
lymphangiomata,  and  although  they  are  always  congenital, 
the  child  may  attain  to  some  age  before  they  are  observed. 
They  grow  from  any  part  of  the  body,  but  they  are  most 


Fig.  5i. — The  same  child,  aged  10  weeks,  after  removal  of  the  cystic  lym- 
phangioma. 

common  in  the  neck  and  axilla.  The  tumour  varies  very 
remarkably  in  different  cases.  It  is  quite  transparent  in 
some,  and  is  clearly  a  simple  sac  filled  with  serous  fluid  ; 
whilst  in  others  it  is  covered  with  normal  opaque  skin  (as 
in  fig.  57),  and   its  fluctuation   is  so  indistinct  that  it  is 


5<DO     THE    SURGICAL    DISEASES    OF    CHILDREN 

likely  to  be  mistaken  for  a  lipoma.  The  cysts  in  these 
more  dense  specimens  are  multiple,  and  vary  greatly  in 
size.  Both  forms  have  far-reaching  connections,  and  the 
surgeon  who  lightly  undertakes  their  removal  is  likely  to 
be  woefully  undeceived  as  to  the  amount  of  dissection 
necessary  to  effect  their  extirpation. 

Treatment.  —  Removal  of  these  tumours  by  careful 
dissection  is  the  proper  treatment  to  be  adopted,  and  this 
can  usually  be  clone  without  much  loss  of  blood,  for  they 
are  not  very  vascular. 

Simple  puncture  is  sometimes  of  service  when  the  cyst 
is  single  and  thin  walled,  but  it  is  useless  in  the  multi- 
locular  forms.  The  smallest  and  simplest  forms  occasion- 
ally disappear  spontaneously.  It  will  sometimes  be  found 
impossible  to  remove  the  whole  of  a  large  tumour  at  one 
operation  ;  so  it  will  be  advisable  to  remove  the  deepest 
part  first,  and  leave  the  outlying  portions  to  be  dealt  with 
at  some  future  time.  In  every  case  the  strictest  asepsis 
must  be  secured,  for  the  wounds  do  not  always  heal 
kindly. 


CHAPTER   XXVI 

BURNS  AND   THEIR   TREATMENT 

The  dangerous  nature  of  burns  and  scalds  in  young 
children  has  long  been  recognised.  If  the  unfortunate 
victims  do  not  die  directly  of  the  shock,  they  pass  through 
a  tedious  and  painful  period  of  suppuration,  and  the  result- 
ing scars  have  a  constant  tendency  to  contract,  leading  to 
revolting  deformities  which  task  to  their  uttermost  the 
resources  of  plastic  surgery. 

Antiseptic  surgery  has  shown  that  the  stage  of  sup- 
puration, if  it  cannot  be  entirely  avoided,  can  at  any  rate 
be  materially  abridged.  The  suppuration  after  a  burn  is 
no  more  necessary  than  it  is  after  any  similar  injury 
leading  to  the  extensive  disintegration  of  tissues.  It  is 
due  to  the  fact  that  the  skin  always  contains  sufficient 
micro-organisms  to  produce  suppuration  when  favourable 
conditions  for  their  growth  are  present,  and  that  these 
organisms  are  extremely  difficult  to  destroy.  They  are 
certainly  not  killed  at  a  temperature  which  may  produce 
a  burn.  For  in  a  child  a  burn  of  the  second  degree  may 
be  caused  by  a  temperature  of  104°  F.,  whilst  the  tougher 
skin  of  an  adult  requires  a  temperature  of  167°  F.  In 
ordinarily  healthy  people,  vesication  does  not  produce 
suppuration  if  the  blisters  are  allowed  to  remain  intact, 
for  the  epithelium  then  prevents  infection  of  the  injured 
surface ;  but  suppuration  easily  occurs  in  the  more  severe 
forms,  where  the  moist  and  absorbent  surface  is  kept  in 
contact  with  dead  and  dirty  skin. 

501 


502      THE    SURGICAL    DISEASES    OF    CHILDREN 

It  is  essential,  therefore,  to  the  aseptic  treatment  of 
burns  that  the  injured  part  and  its  neighbourhood  should 
be  thoroughly  cleansed.  It  is  a  painful  and  lengthy- 
process,  and  the  child  should  be  anaesthetised  whilst  it  is 
being  carried  out.  All  shreds  of  the  tissues  whose  vitality 
have  been  destroyed  ought  to  be  first  cut  away.  The  parts 
should  then  be  lightly  and  thoroughly  washed  with  soap 
and  water,  and  afterwards  with  ether.  This  part  of  the 
operation  must  be  performed  with  the  utmost  gentleness, 
or  more  harm  than  good  will  be  done. 

The  tissues  which  are  now  aseptic  should  be  lightly 
powdered  with  subnitrate  of  bismuth,  and  covered  with  a 
few  layers  of  cyanide  gauze,  protected  with  some  absorbent 
cotton-wool,  the  dressing  being  kept  in  position  by  a  light 
linen  bandage.  It  is  essential  that  the  dressing  should 
be  as  light  as  possible,  and  that  it  should  not  be  changed 
more  often  than  is  absolutely  necessary.  When  suppu- 
ration has  occurred,  the  subnitrate  of  bismuth  may  be 
replaced  by  powdered  salicylic  acid,  after  the  pus  has  been 
carefully  washed  away.  Thiersch's  method  of  skin-graft- 
ing will  greatly  accelerate  the  process  of  healing  as  soon 
as  a  healthy  granulating  surface  has  been  obtained. 

The  objection  to  this  method,  which  is  otherwise  an 
excellent  one,  is  that  it  can  only  be  carried  out  in  a 
hospital.  For  private  practice  it  is  claimed  that  a  satu- 
rated solution  of  picric  acid  yields  the  best  results  for 
burns.  It  allays  pain,  and  prevents  blistering  in  the 
slighter  forms,  whilst  it  acts  as  a  good  antiseptic  in  the 
more  severe  forms. 

The  thiol  treatment,  as  it  is  used  in  Germany,  is  also 
deserving  of  a  trial.  Wash  the  burn  with  a  1  in  2000 
solution  of  corrosive  sublimate.  Cut  away  an}r  blisters 
which  have  been  broken,  but  leave  untouched  those  which 
are  intact.     Dust  boric  acid  all  over  the  parts  which  have 


THE    ANTISEPTIC    TREATMENT    OF    BURNS    503 

been  deprived  of  their  epidermis.  Paint  the  burn  and  the 
surrounding  skin  with  liquid  thiol,  diluted  with  an  equal 
quantity  of  water,  and  then  apply  a  pad  of  absorbent  wool 
over  the  whole.  The  dressing  should  be  renewed  at  the 
■end  of  a  week,  and  it  is  said  that  the  wound  usually  heals 
under  one  or  two  dressings. 

Mr.  Staveley  tells  me  that  he  has  often  obtained  ex- 
cellent results  by  immersing  burnt  children  in  a  bath  at 
100°  F.,  into  which  a  quart  of  boric  lotion,  containing  600 
grains  of  boric  acid,  has  been  well  stirred.  Any  adherent 
clothing  is  allowed  to  soak  off,  and  the  child  is  then  taken 
out,  dried,  and  the  burnt  parts  are  dusted  with  powdered 
iodoform  or  with  subnitrate  of  bismuth.  Dressings  of 
cyanide  or  iodoform  gauze  are  afterwards  applied,  and 
only  renewed  when  it  is  absolutely  necessary  to  do  so. 

The  After -Treatment  of  Burns. 

The  process  of  repair  may  often  be  hastened  by  the 
judicious  grafting  of  skin  in  cases  of  extensive  burns. 
This  method  is  also  of  service,  as  it  prevents  undue  con- 
traction of  the  cicatrices.  It  should  not  be  adopted,  how- 
ever, until  the  injured  surface  has  become  covered  with 
healthy  granulations,  and  every  care  must  be  taken  that 
these  granulations  do  not  become  exuberant. 

Thiersch's  Method  of  Skin-Graftixi;. 

This  method  (p.  GO)  consists  in  rendering  the  skin  and 
the  wound  aseptic.  The  wound  must  be  healthy,  and  its 
base  firm  and  in  a  good  condition  to  facilitate  the  growth 
of  the  capillary  loops  into  the  loose  tissue  upon  the  .under 
surface  of  the  grafts,  so  that  they  may  obtain  a  food- 
supply  quickly.  Very  large  grafts  are  used,  and  as  much 
as  possible  of  tin;  wound  is  covered.  Every  care  must  be 
taken  to  prevent  suppuration  during  the  grafting  period. 


504      THE    SURGICAL    DISEASES    OF    CHILDREN 

The  technique  of  the  operation  is  as  follows.  The  ul- 
cerated surface  and  the  skin  from  which  the  grafts  are  to 
be  taken  is  rendered  sterile  on  the  day  before  the  operation 
by  the  ordinary  means,  and  is  then  dressed  with  a  com- 
press soaked  in  sterilised  06  per  cent,  solution  of  common 
salt.  The  patient  is  anaesthetised,  the  granulations  are 
scraped  away  with  a  sharp  spoon,  the  bleeding  surface  is 
irrigated  with  a  06  per  cent,  salt  solution,  at  a  tempera- 
ture of  105°  F.,  and  is  firmly  compressed  with  sterilised 
gauze  until  the  bleeding  has  stopped. 

The  dressings  in  the  meantime  are  removed  from  the 
prepared  limb.  In  a  child  I  usually  select  the  front  of  the 
thigh ;  the  skin  is  again  washed  with  a  1  in  20  solution 
of  carbolic  acid,  and  is  then  thoroughly  irrigated  with  the 
hot  normal  saline  solution,  to  wash  away  every  trace  of 
the  carbolic  lotion.  The  skin  is  then  made  tense  with  the 
left  hand,  and  as  large  sections  as  possible  are  cut  with 
a  razor  whose  blade  is  wetted  with  the  normal  saline 
solution.  The  sections  should  be  as  long  and  as  broad  as 
possible,  but  they  should  not  encroach  upon  the  true  skinr 
so  that  there  is  no  immediate  bleeding  when  they  are  cut, 
though  there  is  a  little  oozing  afterwards.  The  sections 
are  floated  off  the  razor  on  to  the  surface  of  the  ulcer, 
which  should  now  be  free  from  blood.  They  are  gently 
arranged  by  means  of  a  pair  of  fine-pointed  dissecting 
forceps,  care  being  taken  to  get  the  section  flat,  and  to  see 
that  the  epidermic  surface  is  uppermost.  Each  strip  is 
lightly  pressed  into  place  with  a  spatula,  to  squeeze  out 
any  blood  which  there  may  be  under  it,  and  to  bring  it 
into  intimate  connection  with  the  subjacent  tissue.  When 
all  the  grafts  have  been  put  in  place,  the  edges  of  the 
wound  are  oiled  with  sterilised  oil,  to  prevent  the  gauze 
sticking,  and  the  wound  is  dressed  with  sterilised  gauze, 
to  which  no  antiseptic  has  been  added. 


THE    AFTER-TREATMENT    OF    BURNS  505 

The  gauze  should  be  moistened  with  normal  saline  solu- 
tion for  a  week ;  but  after  that  time  dry  dressings  may 
be  applied,  and  a  little  powdered  nitrate  of  bismuth  may 
be  dusted  over  the  wound.  The  dressings  should  be 
changed  daily,  but  with  the  utmost  care  not  to  disturb 
the  grafts,  which  should  be  gently  irrigated  upon  each 
occasion  with  a  little  warm  salt  solution.  The  limb  from 
which  the  graft  was  taken  must  be  dressed  antisepti- 
cally,  and  it  may  be  left  untouched  until  it  has  healed,  for 
this  usually  takes  place  without  any  hitch.  It  is  many 
months,  however,  before  the  grafts  form  an  integral  part  of 
the  surface  to  which  they  have  been  transplanted,  and 
during  the  whole  of  this  time  they  must  be  protected  from 
injury.  The  operation  is  successful  if  the  grafts  are  pink 
at  the  end  of  a  few  days ;  but  if  they  are  white,  they  are 
going  to  die.  Considerable  experience  has  taught  me  that 
much  of  the  success  of  the  operation  consists  in  having 
the  salt  solution  sterile  and  in  avoiding  as  far  as  possible 
the  use  of  antiseptic  applications. 

Plastic  Operations. 

It  often  happens  that  a  child  is  not  brought  to  a  sur- 
geon for  advice  until  severe  scarring  has  produced  great 
and  permanent  deformity,  for  the  relief  of  which  a  plastic 
operation  is  alone  of  service,  though  shampooing  will 
often  prove  beneficial  in  the  slighter  cases.  The  treat- 
ment of  severe  cicatricial  deformities  after  burns  is 
always  a  subject  of  deep  interest  to  surgeons,  for  it  is 
as  a  rule  most  unsatisfactoiy.  Mr.  Croft  has  recently 
suggested  a  modification  of  the  plastic  operation,  from 
which  he  claims  to  have  obtained  excellent  results.  His 
method  consists  in  raising  a  bridge  of  skin  whose  length 
is  about  three  times  greater  than  its  width.  The  bridge 
is  cut  as  thick  as  possible,  and  as  near  to  the  cicatrix  as 


506     THE    SURGICAL    DISEASES    OF    CHILDREN 

can  be  managed  without  actually  cutting  into  the  scar 
tissue.  It  is  left  attached  at  either  end,  but  it  is  raised 
along  its  whole  extent  so  as  to  allow  the  edges  of  the 
wound  to  be  sutured  together.  When  this  has  been  done, 
a  piece  of  oiled  silk  protective  is  inserted  between  the 
under  surface  of  the  bridge  and  the  line  of  incision,  to  pre- 
vent adhesions  being  formed  between  the  two. 

The  second  part  of  the  operation  is  performed  a  fortnight 
or  three  weeks  later.  It  consists  in  dividing  the  con- 
tracted scar,  cutting  one  end  of  the  bridge  loose  and  trans- 
planting the  flap  in  such  a  way  that  the  bed  and  the  strip 
of  skin  agree  as  far  as  possible  in  shape  and  extent.  The 
under  surface  of  the  strip  usually  recpaires  a  little  paring 
or  freshening,  in  order  to  secure  union  by  first  intention. 

Mr.  Croft  thinks  that  it  is  sufficient  to  obtain  primary 
union  between  the  free  end  of  the  strip  and  the  fresh 
wound  ;  for  if  this  can  be  ensured,  the  rest  will  follow  in 
due  course.  For  scars  in  the  neck  the  skin  was  taken 
from  the  back  of  the  neck  and  from  the  shoulder,  and  the 
strips  were  sufficiently  long  to  cross  the  median  line. 


CHAPTER  XXVII 

SOME  MALFORMATIONS  AND  CONGENITAL 
DEFORMITIES 

SPINA  BIFIDA."7 

"Varieties. — Spina  bifida  is  either  a  meningocele  or  simple 
protrusion  of  the  membranes  covering  the  spinal  cord  ;  or 
it  is  a  meningo-myelocele  when  the  protrusion  contains 
some  of  the  essential  constituents  of  the  spinal  cord  ;  or 
it  is  a  syringo-myelocele  when  the  walls  of  the  cyst  are 
composed  of  the  spinal  cord  itself.  The  sac  in  each  case 
contains  cerebro-spinal  fluid  to  a  greater  or  less  extent. 
The  meningo-myelocele  is  the  commonest  form  ;  syringo- 
myelocele occurs  occasionalh' ;  simple  meningocele  is  very 
rare. 

etiology. — The  condition  is  always  congenital,  and 
its  cause  has  given  rise  to  many  theories.  It  has  been 
supposed  that  a  hernia  of  the  spinal  membranes  has  inter- 
fered with  the  developmental  changes,  leading  to  closure 
of  the  vertebral  arches.  If  this  has  taken  place  early  in 
embryonic  life,  the  skin  may  have  been  replaced  by  a  thin 
membrane;  bul  ii  the  hernia  has  occurred  late,  the  skin 
may  be  normal.  The  skin  over  the  tumour  is  sometimes 
so  completely  replaced  by  scar  tissue  that  it  appears  as 
if  some  forms  of  spina  bifida  were  caused  by  local  inflam- 
mations and  adhesions  "I'  the  foetal  membranes,  leading 
to   modifications   of   the   developmental  processes.     Many 

507 


508      THE    SURGICAL    DISEASES    OF    CHILDREN 

pathologists  of  great  repute  maintain  that  in  such  cases 
the  protrusion  is  permitted  by  a  defective  closure  of  the 
vertebral  arches,  due  to  errors  in  the  development  of  the 
mesoblast  from  which  are  derived  the  structures  forming 
the  roof  of  the  vertebral  canal.  In  a  few  cases  the  defec- 
tive closure  of  the  vertebral  laminae  are  associated  with 
the  presence  of  congenital  tumours  in  the  vertebral  canal, 
such  as  exostoses,  chondromata,  lipomata,  fibromata,  and 
teratomata. 

Morbid  Anatomy.— The  swelling  is  most  common  in 
the  lumbo-sacral  region  of  the  cord,  next  in  the  sacral 
region,  and  afterwards  in  the  dorsal,  lumbar,  and  cervical 
regions.  The  sac  of  a  meningocele  is  developed  from  the 
arachnoid,  and  the  fissure  is  usually  strictly  in  the  median 
line.  It  is  quite  translucent  to  transmitted  light,  and  is 
generally  placed  higher  in  the  vertebral  column  than  the 
other  varieties.  The  defective  closure  of  the  posterior 
portion  of  the  vertebral  column  is  limited  to  the  imme- 
diate seat  of  the  tumour. 

Meningo-myelocele  represents  a  partial  dilatation  of  the 
central  canal.  The  defects  in  the  skin  over  the  tumour 
are  often  very  marked,  and  there  may  be  an  umbilicated 
portion.  When  it  is  seen  by  transmitted  light,  folds 
marking  the  position  of  the  nerve-roots  are  often  distinctly 
visible  within  the  sac.  Large  tracts,  or  even  the  whole  of 
the  vertebral  column,  may  be  imperfectly  developed.  A 
meningo-myelocele  is  often  associated  with  other  congenital 
defects,  such  as  club-foot,  and  more  rarely  ectopia  vesicae. 

The  tumour,  in  cases  of  syringo-myelocele,  is  usually 
smaller  than  in  meningo-myelocele,  the  skin  is  sound,  but 
the  tumour  is  always  placed  laterally,  and  is  often  associ- 
ated with  faulty  development  and  asymmetry  of  the  ver- 
tebrae.    It  is  lined  with  a  layer  of  cylindrical  epithelium. 

Spina  bifida  occulta  occurs  when  there  is  defective  closure 


MALFORMATIONS    AND    DEFORMITIES         509 

of  the  posterior  parts  of  the  vertebrae,  without  any  well- 
marked  protrusion  of  the  spinal  membranes.  It  may  be 
associated  with  hypertrichosis  of  the  affected  part,  some 
anaesthesia,  and  even  with  perforating  ulcers.  It  presents 
a  doughy  swelling,  in  which  deep  pressure  reveals  a 
separation  of  the  vertebral  laminse. 

Diagnosis. — A  spina  bifida  must  be  distinguished  from 
sacro-coccygeal  cysts,  from  lymphangiomata,  from  hard  or 
soft  fibromata,  from  dermoids,  and  from  teratomata.  Pig- 
mented hairy  moles  in  the  middle  line  of  the  vertebral 
column  should  always  be  carefully  examined  to  ascertain 
whether  they  have  a  spina  bifida  occulta  underlying  them. 

Some  forms  of  spina  bifida  are  anterior  instead  of  pos- 
terior, and  in  some  instances  their  presence  is  marked  by 
a  cystic  tumour  overlying  them. 

Prognosis. — The  prognosis  in  syringo-myelia  and  in 
meningocele  is  good,  but  in  meningo-myelocele  it  is  doubt- 
ful. The  tumour  in  many  cases  of  meningo-myelocele  is 
large,  its  skin  is  damaged,  and  many  of  the  posterior 
arches  are  defective.  Inflammation  and  suppuration  are 
therefore  very  likely  to  occur. 

Symptoms. — The  symptoms  are  easily  deduced  from 
the  morbid  anatomy  and  the  pathology  of  the  condition. 
There  is  a  rounded  or  oval  swelling,  which  is  tense,  elastic, 
and  fluctuating.  The  size  of  the  tumour  can  be  reduced 
in  many  cases  by  pressure ;  but  this  must  be  exercised 
with  care,  for  it  is  painful,  and  it  may  cause  twitching  of 
the  limbs,  convulsions,  or  even  coma.  Pressure  upon  the 
spina  bifida  in  infants  may  produce  an  evident  increase  in 
the  tension  of  the  anterior  fontanelle.  The  condition  of 
the  cord  may  lead  to  certain  symptoms  of  physiological 
interest,  for  there  may  be  more  or  less  complete  anaesthesia 
or  even  hyperesthesia  of  the  legs,  with  incontinence  of 
urine,  faeces,  and  other  paralytic  symptoms. 


5IO      THE    SURGICAL    DISEASES    OF    CHILDREN 

Treatment. — Syringomyelocele  does  not  as  a  rule 
require  any  treatment. 

A  meningocele  should  be  protected  from  pressure  or 
from  any  influence  likely  to  produce  inflammation  of  the 
sac.  It  sometimes  undergoes  retrogressive  changes,  which 
lead  to  its  cure.  When  it  is  situated  high  up  in  the  cer- 
vical region,  when  it  is  an  eyesore,  or  when  from  its 
liability  to  injury  there  is  a  danger  of  its  causing  spinal 
meningitis,  it  may  be  removed  aseptically.  The  sac  and 
its  pedicle  are  exposed  by  a  vertical  incision,  and  the 
pedicle  is  compressed  to  prevent  blood  flowing  into  the 
vertebral  canal.  The  sac  is  then  removed,  its  edges  are 
accurately  united  with  aseptic  silk  sutures,  the  pressure 
forceps  are  removed  from  the  pedicle,  and  the  skin  is 
brought  into  such  accurate  apposition  that  union  occurs 
by  first  intention.  The  double  row  of  sutures  appear  to 
be  necessary,  because  in  some  of  the  recorded  cases  there 
has  been  an  uncontrollable  flow  of  cerebro-spinal  fluid  after 
this  operation,  which  has  led  to  a  fatal  termination. 

The  treatment  of  meningo-myelocele  varies  with  each 
individual  case. 

(1)  Palliative. — If  the  tumour  is  small  and  the  skin  is 
fairly  normal,  I  content  myself  with  ordering  a  hollow 
indiarubber  or  leather  cup  for  the  child.  The  edge  of  the 
cup  should  consist  of  an  indiarubber  lip  containing  air, 
like  that  forming  the  edge  of  the  face-piece  of  a  Clover's 
ether-inhaler.  Care  must  be  taken  that  the  cup  is  larger 
than  the  tumour,  so  that  its  edges  may  press  upon  the 
healthy  skin  of  the  back.  The  use  of  such  an  apparatus 
is  purely  protective,  and  in  no  way  curative. 

(2)  By  Injection. — When  the  skin  is  very  unhealthy, 
and  when  the  swelling  is  so  tense  that  it  seems  likely  to 
yield,  the  tumour  must  be  tapped.  This  is  done  with  a 
sterilized  trocar  and  canula,  with  the  child  lying  upon  its 


MALFORMATIONS    AND    DEFORMITIES         5  I  I 

side.  The  trocar  should  be  entered  obliquely  through  the 
healthy  skin  at  one  side  of  the  base  of  the  tumour.  The 
fluid  contents  of  the  sac  are  allowed  to  escape,  and  a 
drachm  of  Morton's  fluid  is  injected  from  a  small  glass 
syringe  connected  with  the  end  of  the  canula  by  a  piece  of 
indiarubber  tubing.  Morton's  fluid  consists  of  ten  grains 
of  iodine,  with  thirty  grains  of  iodide  of  potassium  dis- 
solved in  an  ounce  of  glycerine.  The  fluid  is  allowed  to 
remain  in  the  sac,  the  canula  is  withdrawn,  and  the  punc- 
ture is  sealed  with  a  fragment  of  absorbent  cotton  wool 
soaked  in  collodion.  A  pad  of  Gramgee's  tissue  is  then  put 
on,  and  is  kept  in  place  by  a  lightly  applied  bandage.  The 
child  is  laid  upon  its  side  for  a  few  hours.  The  injection 
usually  has  to  be  repeated  at  intervals  of  a  week  or  ten 
days. 

The  committee  appointed  by  the  Clinical  Society67  to  re- 
port on  spina  bifida  came  to  the  conclusion  that  marasmus, 
hydrocephalus,  and  intercurrent  disease  contra-indicate  the 
operation,  and  that  the  best  results  are  to  be  hoped  for 
in  children  who  have  reached  the  age  of  two  months,  in 
whom  there  is  no  paralysis  or  hydrocephalus,  and  when 
the  sac  is  covered  by  healthy  skin.  The  committee  also 
thought  that  the  operation  was  legitimate,  though  it  was 
performed  under  unfavourable  circumstances,  when  there'is 
distinct  evidence  of  the  cord  being  in  the  sac,  as  shown  by 
its  umbilication  or  by  a  longitudinal  furrow  ;  when  there 
is  a  very  thin  membranous  or  ulcerated  sac;  when  there 
has  been  previous  rupture  of  the  sac ;  when  there  is  a 
distinct  impulse  between  the  tumour  and  the  anterior 
fontanelle ;  when  the  contents  of  the  sac  are  easily  re- 
turned  into  the  spinal  canal,  and  when  the  patient  is  very 
young. 

(3)  Radical. — Excision  of  the  sac  of  a  meningo-myelocele 
is  hardly  a  justifiable  operation  under  ordinary  conditions  ;67 


512      THE    SURGICAL    DISEASES    OF    CHILDREN 

but  in  older  patients  whose  physical  condition  is  very  bad, 
it  may  be  worth  while  to  remove  the  sac,  and  at  the  same 
time  endeavour  to  close  the  defect  in  the  vertebral  column 
by  means  of  an  osteoplastic  operation,  consisting  in  the 
transplantation  of  longitudinal  strips  of  bone  chiselled 
from  each  side  of  the  rudimentary  laminse. 

DERMOIDS  AND   CONGENITAL  CYSTS.68 

Pathology. — Dermoids  and  congenital  cysts  are  of  as 
great  interest  to  the  children's  surgeon,  who  has  to  deal 
with  them  clinically,  as  to  the  pathologist,  who  only  con- 
siders them  for  their  own  sakes.  They  are  the  result  of 
developmental  errors,  and  are  most  frequently  found  at 
those  points  in  the  body  where  layers  of  epiblast  have 
coalesced.  Mr.  Bland  Sutton,  who  has  studied  their  origin 
very  carefully,  shows  that  the  areas  where  they  are  most 
frequent  can  be  divided  into  the  primary  regions,  such 
as  the  dorsal  line  produced  by  the  fusion  of  the  medullary 
folds,  or  along  the  ventral  line  resulting  from  the  closure 
of  the  abdominal  walls.  The  secondary  regions  are  those 
produced  by  the  fusion  of  more  highly  specialized  parts, 
such  as  the  lines  of  closure  of  the  mandibular,  branchial, 
palatine  and  genital  clefts.  Dermoids  are  oftener  found  in 
connection  with  the  secondary  than  with  the  primary 
lines  of  union.  The  origin  of  the  dermoids  and  congenital 
cysts  growing  in  the  floor  of  the  mouth  and  in  the  neck 
has  lately  received  special  attention.  They  are  either 
lateral  or  they  are  median.  Some  of  the  median  tumours, 
and  the  majority  of  those  situated  laterally,  are  branchial 
in  origin.  Many  of  the  median  tumours,  and  a  few  of 
those  which  appear  to  be  lateral,  are  derived  from  the 
thyreo-glossal  duct  or  from  the  sinus  prsecervicalis.  The 
thyreo-glossal  duct  runs  from  the  thyroid  gland  behind 


MALFORMATIONS    AND    DEFORMITIES         5  I  3 

the  hyoid  bone  to  the  foramen  csecum  in  the  tongue.  It 
commences  as  a  bifurcated  tube,  which  unites  below  or 
behind  the  hyoid,  and  is  continued  upwards  as  the  lingual 
duct.  It  is  lined  with  columnar  ciliated  epithelium, 
except  at  its  upper  part,  where  the  cells  are  squamous. 
The  duct  ought  to  be  obliterated  completely,  but  it  may 
remain  patent,  either  wholly  or  in  part.  Dr.  Herbert  E. 
Durham  has  lately  examined  the  pathology  of  the  con- 
genital tumours  formed  in  connection  with  the  thyreo- 
glossal  duct  in  a  very  able  and  lucid  manner,  and  his 
results  are  published  iu  the  77th  volume  of  the  Trans- 
actions of  the  Royal  Medical  and  Chirurgical  Society. 

Congenital  cysts  may  also  be  found  in  an  unobliterated 
sinus  prsecervicalis  situated  in  the  position  of  the  third 
and  fourth  branchial  arches.  They  may  be  placed  laterally 
when  they  are  developed  in  connection  with  a  branchial 
cleft,  or  they  may  have  been  median  originally,  becoming 
displaced  to  one  or  other  side  by  pressure  of  the  muscles. 
They  are  either  thin-walled  with  serous  contents,  or 
thicker-walled  with  a  more  mucoid  substance.  Their 
walls  are  composed  of  connective  tissue  lined  with  cylin- 
drical ciliated  cells,  and  in  this  manner  they  may  be 
distinguished  from  the  lymphatic  nsevi  which  have  an 
endothelial  lining. 

Dermoids  are  cysts  containing  sebaceous  material  alone, 
or  sebaceous  material  with  hair.  Their  walls  consist  of 
skin,  with  sweat  and  sebaceous  glands,  and  hair  follicles 
may  also  be  present. 

Diagnosis. — Dermoids  and  congenital  cysts  are  very 
liable  to  be  mistaken  for  sebaceous  cysts,  for  abscesses, 
for  spina  bifida,  for  meningocele,  for  encephalocele,  and  for 
a  ranula  if  the  tumour  is  on  the  floor  of  the  mouth. 

Treatment. — Dermoids,  when  they  are  small,  when 
they  are  not  unsightly,  and  when  they  show  no  tendency 

L    L 


514      THE    SURGICAL    DISEASES    OF    CHILDREN 

to  inflame,  had  better  be  left  alone.  They  may  suppurate, 
and  the  surgeon  must  then  remove  them,  taking  care  to 
enucleate  them  without  rupture  of  the  sac,  and  being  pre- 
pared for  a  much  more  extensive  operation  than  the  super- 
ficial appearance  of  the  tumour  would  seem  to  warrant. 
The  wound  often  heals  badly,  in  spite  of  every  precaution. 
The  smaller  congenital  cysts  may  be  tapped,  but  the 
larger  ones  generally  refill ;  so  that  it  is  best  to  remove 
them  bodily  if  it  is  necessary  to  perform  any  operation 
upon  them.  Cysts  which  are  presumably  formed  in  con- 
nection with  the  thyreo-glossal  duct  sometimes  require  a 
very  extensive  operation  for  their  extirpation.  The  hyoid 
bone  may  require  division  and  subsequent  suture  ;  for  ob- 
stinate fistulas  are  often  left,  unless  the  whole  of  the  duct 
be  extirpated. 

SACRO-COCCYGEAL  CYSTS. 

etiology.— The  sacro-coccygeal  tumours  form  a  com- 
plex but  by  no  means  a  frequent  class  of  tumours. 

Pathology.— They  are  divided  into  several  groups,  of 
which  the  most  interesting  are  the  teratomata.  In  their 
most  highly  developed  form,  these  tumours  are  included 
foetuses,  though  in  some  cases  they  are  mere  masses  of 
highly  organised  tissues  possessing  a  rudimentary  skeleton, 
whilst  others  again  approach  more  nearly  to  the  type  of 
rhabdomyomata. 

The  cystic  tumours  are  either  simple  or  compound,  the 
latter  being  innocent  or  malignant.  Such  cysts  are  of 
importance,  for  they  are  likely  to  be  mistaken  for  spina 
bifida,  though  they  occur  in  the  coccygeal  region,  where  a 
spina  bifida  is  rarely,  if  ever,  seen.  The  majority  of  the 
cystic  tumours  grow  from  the  anterior  surface  of  the 
coccyx,  and  only  project  backwards  as  a  secondary  result 


MALFORMATIONS    AND    DEFORMITIES         515 

of  their  growth.  They  appear  to  be  remnants  of  that 
development  in  the  coccygeal  region  which,  attaining  its 
maximum  during  the  fifth  month  of  intra-nterine  life,  be- 
gins to  atrophy  during  the  sixth  month,  and  should  have 
disappeared  at  birth.  The  cysts  are  sometimes  replaced 
by  the  primitive  series  of  canals  lined  with  cylindrical 
epithelium  embedded  in  connective  tissue  containing  car- 
tilage and  bone. 

The  various  forms  of  fibro-lipomata,  or  even  gliomata, 
are,  from  a  structural  point  of  view,  the  simplest  group  of 
sacro-coccygeal  tumours.  They  may  be  extremely  vas- 
cular, and,  like  the  cystic  tumours,  they  usually  gi'ow  from 
the  connective  tissue  lying  between  the  rectum  and  the 
coccyx. 

Symptoms. — The  symptoms  vary  greatly  with  the  nature 
of  the  tumour.  The  most  highly  developed  form,  the  in- 
cluded foetus,  may  possess  the  power  of  reflex  excitability, 
whilst  the  more  lowly  organised  teratomata  hardly  differ 
from  the  solid  tumours.  The  cystic  forms  may  be  intra- 
pelvic  or  extrapelvic.  An  interesting  example  of  the 
intrapelvic  form  came  under  my  care  last  year  in  a  girl 
aged  two  months,  who  suffered  from  retention  of  urire 
caused  by  its  pressure  upon  the  ureters.  A  bimanual 
examination  through  the  rectum  and  the  abdomen  revealed 
a  tense  and  elastic  swelling  upon  the  right  side,  extending 
from  the  pubes  to  the  umbilicus.  The  swelling  was  fixed, 
it  was  pyriform  in  shape,  the  upper  broad  end  being 
rounded  and  sharply  defined.  I  performed  a  median 
laparotomy,  but  found  that  the  tumour  was  too  deeply 
seated  and  too  firmly  fixed  to  allow  of  its  removal.  The 
child  died  with  diarrhoea  two  days  after  the  operation. 
The  bladder  was  found  at  the  post-mortem  examination 
to  be  much  thickened,  the  ureters  were  dilated,  and 
the  kidneys  were  in  a  condition  of  hydronephrosis.     The 


5  1 6      THE    SURGICAL    DISEASES    OE    CHILDREN 

uterus,  ovaries,  and  Fallopian  tubes  were  normal.  The 
rectum  for  an  inch  above  the  anus  was  also  normal,  but 
immediately  above  this  point  a  large  oval  swelling  pro- 
jected into  its  lumen  without  causing  any  gross  lesion. 
This  swelling,  as  is  seen  in  fig.  59,  was  part  of  a  tumour 
which  sprang  from  the  right  side  of  the  rectum,  and 
was  apparently  in  intimate  connection  with  it.     The  out- 


Fig.  59. — Pelvic  organs,  showing  a  congenital  cyst  projecting  into  the  upper 
part  of  the  rectum.  R,  The  rectum  laid  open  laterally  to  show  the  projection 
of  the  cyst  into  its  interior ;  C,  the  cyst,  showing  the  manner  in  which  it 
tapered  into  a  fine  cord  G,  which  was  lost  in  the  connective  tissue  behind  the 
rectum  ;  U,  the  uterus  with  the  two  ovaries  hanging  over  upon  its  right  side  ; 
B,  the  thickened  bladder. 

[From  the  "  Transactions  of  the  Pathological  Society  of  London."] 

lines  of  the  cyst  were  smooth  and  uniform,  except  at  its 
lower  part,  where  it  suddenly  tapered  off  into  a  thin  and 
delicate  cord,  consisting  only  of  the  lining  membrane  of 
the  cyst.  This  cord  soon  lost  itself  in  the  loose  connec- 
tive tissue  lying  between  the  lower  part  of  the  rectum 


MALFORMATIONS    AND    DEFORMITIES         517 

and  the  coccyx.     The  cyst  contained  a  mucous  fluid,  and 
was  lined  with  cylindrical  and  ciliated  epithelium. 

The  extrapelvic  cysts  and  tumours  are  usually  irregular 
in  outline,  and  they  vary  in  consistence  at  different  parts. 
There  is  often  no  doubt  as  to  their  origin  from  the  front 
of  the  coccyx,  for  the  space  between  the  anus  and  the 
coccyx  may  be  so  much  increased  as  very  greatly  to  reduce 
the  width  of  the  perineum.  In  some  cases,  however,  the 
tumours  pass  along  the  side  of  the  coccyx,  and  their  exact 
origin  is  then  more  difficult  to  determine. 

Treatment. — The  treatment  of  an  included  foetus  con- 
sists in  removal  of  the  projecting  part  and  suture  of  the 
skin  over  the  stump.  The  intrapelvic  tumours  sometimes 
remain  unrecognised  for  many  years,  until,  by  projecting 
into  the  rectum,  they  may  give  rise  to  symptoms,  or  they 
may  themselves  suppurate.  The  extrapelvic  forms  may 
be  excised  if  the  surgeon  can  assure  himself  that  they  are 
not  in  direct  connection  with  the  vertebral  canal. 

The  simple  cystic  tumours  may  be  treated  by  aseptic 
tapping  ;  but  the  more  complex  varieties  must  be  removed 
completely  if  the  surgeon  feels  satisfied  that  this  can  be 
done ;  otherwise  they  had  better  be  left  alone.  He  should 
always  remember,  however,  that  their  attachments  extend 
much  more  deeply  than  their  superficial  appearances  in- 
dicate. 


CONGENITAL  HYDROCELE   OF  THE  NECK. 

Children  are  sometimes  born  with  very  large  hydroceles 
of  the  neck,  which  appear  to  be  developed  in  connection 
with  the  branchial  arches,  and  are  to  be  distinguished  from 
the  cystic  lymphangiomata  described  at  p.  497. 


5  1 8     THE    SURGICAL    DISEASES    OF    CHILDREN 

CONGENITAL  UMBILICAL  POLYPUS. 

Mucous  polypi,  developed,  Mr.  Pearce  Gould  supposes, 
from  the  remains  of  the  umbilical  vesicle,  are  occasionally 
seen  springing  from  the  navel  either  at  birth,  or  after  the 
umbilical  cord  has  dropped  off.  The  treatment  consists 
in  ligaturing  the  pedicle  and  snipping  off  the  growth.  The 
polypus  consisted,  in  Mr.  Gould's  case,  of  branched  mucous 
glands  lined  with  columnar  epithelial  cells  embedded  in  a 
very  vascular  stroma  of  connective  tissue.  A  fgecal  fistula 
may  be  produced  at  the  umbilicus  from  persistence  of  the 
ductus  vitello-intestinalis,  or  from  its  imperfect  oblitera- 
tion a  sac  with  muscular  walls  and  attached  to  the  small 
intestine  may  be  present  at  the  umbilicus,  as  Mr.  Heaton 
has  shown. 

Abnormalities  of  the  Urachus.  —  etiology.  —  The 
urachus  ought  to  be  obliterated  soon  after  birth,  but  it 
may  remain  pervious  either  in  part  or  throughout  its 
whole  extent.  Cysts  sometimes  form  in  a  partially 
patent  urachus,  and  when  it  is  wholly  unclosed  there 
may  be  a  true  vesico-umbilical  fistula  through  which 
the  urine  is  discharged.  I  have  known  such  a  condition 
develop  in  a  child  whose  micturition  was  impeded  by  a 
sarcoma  growing  in  its  bladder. 

PNEUMATOCELE  CPANII. 

A  remarkable  form  of  tumour  is  occasionally  met  with 
in  children.  It  is  situated  upon  the  skull,  and  is  tense, 
well  defined,  and  painless.  Its  size  can  be  reduced  by 
pressure.  It  is  often  congenital,  but  it  occasionally 
appears  suddenly,  and  without  any  cause.  It  is  generally 
situated  over  the  temporal  bone,  but  its  method  of  forma- 
tion is  quite  unknown.  Puncture  of  the  tumour  through 
the  pericranium  allows  air  to  escape,  but  it  soon  refills ; 


MALFORMATIONS    AND    DEFORMITIES         519 

and  as  its  size  can  be  increased  by  strong  expiratory 
efforts,  there  is  no  doubt  that  it  has  a  direct  connection 
with  the  respiratory  passages,  probably  through  the  ear. 

Treatment.— Firm  pressure  may  be  tried,  but  it  is 
generally  useless.  Wernher  gives  an  account  of  one  case 
which  was  completely  cured  after  the  fourth  injection 
of  tincture  of  iodine.  Sonnenberg  maintains  that  these 
tumours  are  best  treated  by  incision,  to  allow  them  to  heal 
by  granulation. 

GIANT  GROWTH. 

Curious  cases  of  giant  growth  are  sometimes  brought 
for  advice.  The  condition  is  congenital,  and  usually  affects 
the  hands  and  feet.  The  extremities  are  sometimes  normal, 
but  they  appear  to  belong  to  a  giant.  It  was  doubtless 
the  occurrence  of  such  cases  that  led  Pliny  to  report, 
"  Eosdemque  Sciopodas  vocari,  quod  in  majori  aestu  humi 
jacentes  resupini,  umbra  se  pedum  protegant,"  which 
Philemon  Holland  translates,  "  The  same  men  are  also 
called  Sciopodes,  for  that  in  the  hotest  season  of  the 
summer  they  lie  along  on  their  back  and  defend  them- 
selves with  their  feet  against  the  sunnes  heat."  A 
comparison  of  fig.  60  with  that  given  in  the  sixteenth 
century  English  Manuscript  of  Sir  John  Maundeville 's 
Voiage  and  Travaile,  in  the  Library  of  the  British 
Museum  (8  Harl.,  3954,  fol.  31),  will  show  how  close  is  the 
resemblance  between  what  the  old  traveller  described  from 
tradition  and  what  sometimes  actually  exists  in  nature. 

Many  cases  of  giant  growth  present  evidence  of  trophic 
disturbances  in  the  form  of  impaired  sensibility,  or  in 
peculiarities  of  pigmentation.  The  condition  may  there- 
fore be  due  to  neurotic  causes  affecting  the  tissues,  as 
is  held  by  Widcnmann,  or  it  may  be  produced  by  a  per- 
manent vaso-motor  disturbance,  as  is  maintained  by  Trelat 


520     THE    SURGICAL    DISEASES    OF    CHILDREN 


and  Monod.      Both   explanations,    however,    are  unsatis- 
factory, and  are  merely  a  cloak  to  our  ignorance. 

The  patient  from  whom  the  annexed  photograph  (fig. 
60)  was  taken  has  been  under  my  care  since  she  was  a 
few  months  old.  The  disproportion  between  her  feet  and 
the  rest  of  her  body  becomes  less  as  she  grows  older.  The 
overgrowth  is  symmetrical,  and  affects  the  front  of  each 


Fig.  60.— Congenital  overgrowth  of  the  feet  in  a  child  aged  4  years,  with 
secondary  hypertrophy  of  the  legs. 

foot,  the  heel  and  the  os  calcis  not  being  implicated  to  the 
same  extent.  The  hypertrophy  of  the  legs  is  secondary  to 
the  weight  of  the  feet,  for  the  patient  is  perfectly  able  to 
walk  about,  and  it  did  not  exist  when  she  was  an  infant. 
So  far  as  I  have  been  able  to  ascertain,  the  bones  of  the 
feet  are,  and  always  have  been,  affected  to  the  same  extent 
as  the  soft  tissues. 


APPENDIX    OF    REFERENCES 


The  order  is  that  of  the  chapters  in  the  body  of  the  xcork. 


(1)  Raynaud's  Disease. 

The  Original  Thesis,  with  an  Appendix  by  Dr.  Barlow  the 
translator.  New  Sydenham  Society.  Selected  Mono- 
graphs, 1888,  vol.  cxxi.  pp.  1-199. 

(2)  Typhoidal  Gangrene. 

Dawtrey  Drewitt.  On  Gangrene  of  the  Limbs  following 
Typhoid  bever.     Lewis,  1894. 

(3)  Angina  Ludovici  or  Submaxillary  Cellulitis. 

D.  Ludwig.   Medicinisches  Corrcspondenzblatt,  Band  6, 1836, 

p.  21. 
R.  W.  Parker.     The  Lancet,  1879,  ii.  pp.  571,  607. 
W.  Morrant  Baker.    St.  Barthol.  Hosp.  Rep.,  26,  p.  275. 

(4)  Acute  Retropharyngeal  Abscess. 

B6kai.    Jahrb.f.  Kinderheilk..  i.  183,  x.  108. 
Bilton  Pollard.     The  Lancet,  1892,  i.  350. 
Karewski.     Berliner  Klinik,  March,  1893. 

(5)  Actinomycosis. 

Dr.  Douglas  Powell.     Trans.  Medico-Chir.  Soc,  vol.  lxxii. 

p.  175. 
Pringle.     Trans.  Medico-Chir.  Soc,  vol.  lxxviii.  p.  21. 

(6)  Whitlow. 

Baker.     St.  Barthol.  Hosp.  JRep.}  vol.  xxv.  p.  185. 

(7)  Tuberculous  Diseases  of  Bones  and  Joints. 

Watson  Cheyne.     The  Lancet,  1890,  ii.  ;    The  Brit.  Med. 

Journ.,  1891,  i. 
Senn.     Trans.  American  Surg.  Assoc.,  ix.,  1891,  287. 
Perl  is.     These  de  Paris,  1892-3,  No.  62. 
Mauclaire.     These  de  Paris,  1892-3,  No.  137. 
House  and  Pitt.     Guy's  Hosp.  Rep.,  49,  p.  169. 

521 


522        APPENDIX  OF  REFERENCES 

(8)  Cariks  of  the  Spine  followed  by  Compression  of  the  Cord. 

Eskridge.  The  New  York  Med.  Journ.,  vol.  lx.,  1894, 
pp.  609,  641. 

(9)  Hypertrophic  Pulmonary  Osteo-Arthropathy. 

Felix  Jamet.     These  de  Paris,  1892-3,  No.  221. 
Thorburn.     The  Brit.  Med.  Journ.,  1893,  i.  p.  1155. 
Demons  and    Binaud.      Arch.  yen.  de  Med.,  Aug.,  1894, 
p.  129. 

(10)  Disease  of  the  Sterno-Clavicular  Joint. 

Fonlladosa.     These  de  Paris,  1893-4,  No.  8. 

(11)  Tuberculosis  of  the  Sacro-Iltac  Joint. 

Van  Hook.     The  Annals  of  Surgery,  vols,  viii.,  ix. 

(12)  Osteopsathyrosis  or  Fragilitas  Ossium. 

Moreau.     These  de  Paris,  1893-4,  No.  136. 
Blanchard.     Trans.  Amer.  Orthopcedic  Assoc,  vi.  p.  83. 

(13)  Separation  of  Epiphyses. 

Jonathan  Hutchinson,  jun.  The  Jacksonian  Prize  Essay 
for  1888.  The  Brit.  Med.  Journ.,  1893,  ii.  p.  1417  ;  1894, 
ii.  p.  965. 

Mavo  Robson.     The  Annals  of  Suryery,  vol.  xviii.  p.  1. 

A.  H.  Tubby.  Guy's  Hosj).  Rep.,  vol.  xlvi.,  1889,  p.  267 ; 
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C.  A.  Sturrock.     Edinburgh  Hosp.  Rep.,  ii.,  1894,  p.  598. 

(14)  Traumatic  Meningocele. 

Conner.     Trans.  American  Surq.  Assoc,  ii.,  1884,  p.  55. 
Clement  Lucas.     Guy's  Hosp.  Rep.,  1876-8-81-84. 
Thos.  Smith.     St.  Barthol.  Hosp.  Rep.,  xx.  p.  233. 
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A.  Q.  Silcock.     Trans.  Clin.  Soc,  xxi.  p.  285. 
Shattock.     Trans.  Path.  Soc,  37,  p.  367. 

(15)  Fractures  at  the  Elbow-Joint. 

Dulles.    The  Boston  Med.  and  Surg.  Journ.,  131,  pp.  208, 221. 
Smith.     The  Boston  Med.  and  Surg.  Journ.,  131,  p.  413. 
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(16)  Arthrodesis. 

Renault.     These  de  Paris,  1892-3,  No.  395. 

(17)  Scurvy. 

Thos.  Smith.     Trans.  Path.  Soc,  27,  p.  219. 

Barlow.    Medico-Chir.  Trans.,  66,  p.  159  ;  Brit.  Med.  Journ. 

1894,  ii.  p.  1029. 
Colcott  Fox.     Tram.  Path.  Soc,  38,  p.  275,  and  41,  p.  237. 
Holmes  Spicer.     Trans.  Ophthalmol.  Soc,  xii.  p.  33. 

(18)  Knock-Knee. 

Dambries.     These  de  Paris,  1893-4,  No.  285. 
Sombret.     These  de  Paris,  1893^4,  No.  323. 
Humphry.     Trans.  Medico-Chir.  Soc,  vol.  lxxii.  p.  165. 


APPENDIX  OF  REFERENCES        523 

(18a)     Suppurative  Arthritis  occurring  in  the  course  of  Ex- 
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Mauclaire.     Arch.  gen.  de  Med..  1894-5. 

(18b)     Gonorrheal  Arthritis  in  Infants. 

Widmark.     Jakrbuch  f.  Kinderheilk.,  25,  1886,  p.  157 ; 

Archivf.  Kinderheilk.,  7,  1886,  p.  1. 
Koplik.     Xew  York  Med.  Journ.,  51, 1890,  p.  678. 
Richardiere.     Union  Med.,  Oct.  26th,  1893,  p.  580. 

(19)  Hemophilic  Arthritis. 

KOnig.     Vo/kmamfs  Sammlung,  N.  F.  xi.,  1892. 

A.  E.  Wright.     The  Brit.  Med.  Journ.,  1894,  ii.  p.  57. 

(20)  Anchylosis  of  Jaws. 

Cabot.     The  Annals  of  Surgery,  x.  426. 
Swain.     The  Lancet,  1894,  ii.  187. 

(21)  Dislocations  of  the  Phalanges. 

Battle.     Annals  of  Surgery,  ix.  p.  280 ;  The  Lancet,  18S8, 
ii.  pp.  1223,  1271. 

(22)  Scarlatinal  Arthritis  leading  to  Dislocation  of  Hip. 

Ewens.     Prov.  Med.  Journ.,  vol.  xi.,  1892,  p.  352. 

(23)  Congenital  Displacement  of  the  Hip. 

Wm.  Adams.     The  Brit.  Med.  Journ.,  1885,  ii.  859 ;  1887,  i. 

866. 
Barwell.     Trans.  Medico-Chir.  Soc,  vol.  lxxv.  p.  261. 

(24)  Habitual  Dislocation  of  the  Fibula. 

Aldibert.     Rev.  mens,  des  mal.  de  Venfance,  xii.,  1894,  pp. 
607,  653. 

(25)  Enlarged  Tonsils. 

Felix  Senior).     *SV.  Thomas'1  Hosp.  Rep.,  xiii.  pp.  129-156. 
De  Santi.     The  Lancet,  1894,  i.  p.  83. 

(26)  Adenoids. 

Czermak.        Selected   Monographs,  New  Sydenham  Soc, 

1861,  vol.  xi.  pp.  79,  80. 
Meyer.     Trans.  Internal.  Congress,  1881.  iii.  pp.  278-301. 
Proceedings  Lari/ngological  Soc,  vol.  i.  1894,  p.  94. 
Bartoli.     These  de  Paris,  1892-3,  No.  393. 
C  A.  Parker.     Postnasal  Growths.     Lewis,  1894. 

(27)  Acute  Tubercular  Ulceration  of  the  Fauces. 

Abercrombie  and  Gay.     Trans.  Medico-Chir.  Soc,  vol.  lxx. 
p.  93. 

(28)  Supernumerary  Auricles  or  Preauricular  Appendages. 

Ballantyne.     Teratologia,  ii.,  1895,  p.  18. 

(29)  Otitis  Media. 

Walker  Downie.     The  Brit.  Med.  Journ.,  1894,  ii.  p.  1163. 

(30)  Mastoid  Disease. 

Edmunds.     Si.  Thomas'  Hosp.  Rep.,  xvi.,  1887,  p. 247. 
Arbuthnot  Lane.     The  Brit.  Med.  Journ.,  1893.  ii.  561. 
Macewen.    Pyogenic  Diseases  of  the  Brain  and  Spinal  Cord. 


524  APPENDIX    OF    REFERENCES 

(31)  Thrombosis  of  the  Cerebral  Sinuses. 

Von  Dusch.     Selected  Monographs,  New  Sydenham  Soc, 

vol.  xi.,  1861,  p.  81. 
Ballance.     Trans.  Med.  Soc.  of  Lond.y  xiii.,  1890,  345. 
Pitt.     Brit.  Med.  Journ.,  1890,  i.  643. 

(32)  Non-Tuberculous  Meningitis. 

Gee  and  Barlow.     St.  Barthol.  Hosp.  Rep.,  vol.  xiv.,  1878, 

p.  23. 
Netter.     Arch.  gen.  de  Med.,  vols,  clix.,  clx.  (1887). 
Pitt.     Brit.  Med.  Journ.,  1890,  i.  771. 
Vaudremer.     These  de  Paris,  1892-3,  No.  337. 

(33)  Puncture    of    the    Vertebral    Column    in    Tuberculous 

Meningitis. 
Essex  Wynter.     The  Lancet,  1891,  i.  981. 
Quincke.    Berl.  Bin.  Woch.,  1891,  929. 
Ziemssen.     Wien.  med.  Presse,  vol.  xxxiv.,  1893,  p.  738. 
Hirschberg.     Deutsch.  Arcliiv  f.  lelin.   Med.,  vol.  xli.   p. 

527. 

(34)  Cranio-Cerebral  Topography. 

Fouillehouze.     These  de  Paris,  1876. 

Dana.     New  York  Med.  Record,  vol.  xxxv.  p.  34. 

(35)  Surgery  op  the  Lateral  Ventricles  op  the  Brain. 

Keen.      The  Philadelphia  Med.  News,  53,  1888,  p.  603  ; 

Trans.  Internat.  Congress,  1890,  Bd.  iii.  p.  108. 
Broca.     Rev.  de  Vhir.,'xL.  1891,  p.  37. 
The  details  of  Swift's  case  are  to  be  found  in  the  Dublin 

Quarterly  Journ.  of  Med.  Sci.  for  1847,  vols,  iii.,  iv.,  pp. 

384,  and  p.  1 ;   Brain,  vol.  iv.,  1881,  p.  493.     See  also 

The  Academy,  vol.  xix.  p.  475  and  vol.  xxiv.  p.  64. 

(36)  Intubation. 

Bouchut.     Bull,  de  VAcad.  Nation.,  vol.  xxiii.  p.  1160. 
Trousseau's  Report  upon  this  communication   is  in  the 

succeeding  volume,  p.  99. 
O'Dwyer.     New  York  Med.  Journ.,  vol.  xlii.  p.  145,  and 

The  Brit.  Med.  Journ.,  1894,  ii.  p.  1478. 
Prescott  and  Goldthwait.     Boston  Med.  and  Surg.  Journ., 

vol.  cxxv.  p.  694. 
Carstens.     Jahrb.f.  Kinderheilk.,  Bd.  38,  heft  2,  3,  p,  259. 

(37)  Tracheotomy. 

Van  Arsdale.     The  Annals  of  Surgery,  i.  97. 
Pitts  and  Brook.     The  Lancet,  1891,  i.  pp.  76,  137. 
Parker.     Diphtheria,  its  Nature  and  Treatment,  ed.  3, 1891. 

(38)  Foreign  Bodies  in  the  Air  Passages. 

Cheadle   and   Smith.     Trans.  Med.-Chir.  Soc,  vol.  Ixxi. 

p.  113. 
Bryant.     Trans.  Medico-Chir.  Soc,  vol.  lxxii.  p.  441. 
Good.     St.  Barthol.  Hosp.  Rep.,  vol.  xxvii.  p.  251. 


APPENDIX  OF  REFERENCES        525 

(39)  Empyema. 

Estlander.     Rev.  mens,  de  Med.  et  de  Chir.,  iii.  157,  S85. 
Godlee.     The  Lancet,  1886,  i. 

Brothers.     Archives  of  Paediatrics,  xi.,  1894,  pp.  115,  177. 
Transactions  of  the  Amer.   Surg.   Assoc,   vol.   xii.,    1S94, 
p.  11. 

(40)  Purulent  Pericarditis. 

Rosenstein.    Berl.  klin.  W'och.,  1881,  p.  61. 
Bronner.     The  Brit.  Med.  Joum.,  1891,  i.  351. 
Davidson.     The  Brit.  Med.  Joum.,  1891,  i.  578. 
KCrte.     Deutscli.  vied.  Wocli.,  1892,  p.  35. 

(11)       TURERCULOUS    PERITONITIS. 

Aldibert.     These  de  Paris,  1892,  No.  139. 

(42)  Peritonitis  due  to  the  Pneumococcus. 

Lecoq.     These  de  Paris,  1892-3,  No.  277. 

(43)  Peritonitis  in  the  New-Born. 

Virchow's  Archie,  vol.  xcvi.  p.  307  ;  exxvi.  p.  485. 
Ballantyne.     Edinburgh  Med.  Joum.,  vol.  xxxv.,  part  ii. 
p.  865. 

(44)  Intussusception. 

Barker.     The  Lancet,  1892,  i.  79  ;  Brit.  Med.  Joum.,  1894,  i. 

345. 
Lockwood.     The  Lancet,  1893,  i.  1303. 
McAdam  Eccles.     St.   Barthol.   Hosp.   Pep.,   vol.  xxviii. 

p.  97. 

(45)  Chronic  Intussusception. 

Hutchinson.     Trans.  Medico-Chir.  Soc,  vol.  lvii.  p.  31. 

(46)  Hernia. 

Swasey.     Amer.  Joum.  of  Obstetrics,  vol.  xiii.  p.  679. 
Rushton  Parker.     The  Brit.  Med.  Joum.,  1893,  ii.  1037. 
Lockwood.     The  Lancet,  1893,  ii.  1297. 
Felizet.     Les  Hernies  inguinales  de  Venfance,  Paris,  1894. 

(47)  Prolapse  of  the  Rectum.     Coi.opexy. 

Gerard-Marchant.     Bull,  et  Mem.  de  la  Soc  de  Chirurgie, 
vol.  xvi.  p.  S28  ;  xviii.  p.  153. 

(48)  Congenital  Imperfections  of  the  Rectum. 

Curling.     Trans.  Medico-Chir.  Soc,  vol.  xliii.  p.  271. 
Cripps.     St.  Barthol.  Hosp.  Pep.,  vol.  xviii.  p.  65. 
Anders.     Langenbeck's  Archiv,  vol.  xlv.  p.  489. 

(49)  Surgery  of  the  Kidney. 

Csesar   Hawkins.       Trans.  Medico-Chir.  Soc,    vol.    xviii. 

]).   17:"). 

Stanley.     Trans.  Mrdico-Chir.  Soc,  vol.  xxvii.  p.  1. 
Haviland.     Trans.  Path.  Soc,  x.,  1859,  p.  209. 
Morris.     Trans.  Medico-Chir.  Soc,  vol.  lix.  p.  227. 
Day  and  Thornton.     'Trans.  Path.  Soc,  vol.  xxxi.  p.  167. 


526 


APPENDIX    OF    REFERENCES 


(49)  Surgery  of  the  Kidney  (continued) — 

Barker.     The  Lancet,  1885,  i.  p.  141. 
Parker.     Trans.  Medico-Chir.  Soc,  vol.  lxx.  p.  253. 
Monod.     Ann.  des  mal.  des  org.  genito-urin.,  1892,  p.  342. 
Aldibert.     Rev.  mens,  des  mal.  de  Venfance,  Oct.  and  Nov., 

1893. 
Byron  Robinson.     Annals  of  Surgery,  vol.  xviii.  p.  402. 

(50)  Surgery  of  the  Ureters. 

Fenger.     Annals  of  Surgery,  vol.  xx.,  and   Trans.  Amer. 
Surg.  Assoc,  xii.  p.  129. 

(51)  Tuberculous  Kidney. 

Clement  Lucas.     The  Brit.  Med.  Journ.,  1883,  ii.  611. 

(52)  Malignant  Tumour  of  the  Kidney. 

Abbe.     Annals  of  Surgery,  vol.  xix.  p.  58. 

(53)  Vesical  Calculus. 

Vargas.     Arch,  of  Paediatrics,  vii.,  1890,  p.  241. 
Senn.     Philadelphia  Med.  News,  July,  1893,  10. 
Southam.     The  Brit.  Med.  Journ.,  1894,  i.  54. 
Morgan.     Trans.  Medico-Chir.  Soc,  vol.  lxxiv.  p.  85. 

(54)  Traumatic  Rupture  of  the  Urethra. 

Barling.     Birmingham  Med.  Rev.,  vol.  xxx.  p.  321. 
Delaunai.     These  de  Paris,  1893-4,  No.  122. 

(55)  Prolapse  of  the  Urethra. 

Bryant.     Trans.  Medico-Chir.  Soc,  vol.  lxxvii.  p.  247. 
Guersant.     Bull.  gen.  de  Therapeut.,  vol.  lxxi.,  1866,  p.  307. 

(56)  Phimosis. 

James.     Edinburgh  Med.  Journ.,  vol.  xxiii.  p.  135. 
Felizet.     De  la  Circoncision,  Paris,  1891. 

(57)  Dislocation  of  the  Penis. 

Annals  of  Surgery,  vol.  xi.,  1890,  p.  293. 

(58)  Enuresis  Nocturna. 

Peyer.     Clinical  Lectures  on  Medicine  and  Surgery,  New 
Sydenham  Society,  vol.  cxlviii.  p.  327. 

(59)  Tuberculous  Testicle. 

Koplik.  Arch,  of  Paediatrics,  vol.  vi.,  1889,  p.  891. 
Jul  lien.  Arch.  gen.  de  Med.,  vol.  clxv.,  1890,  p.  420. 
Hutinel  and  Deschamps.    Arch.  gen.  de  Med.,  vol.  clxvii., 

1891,  pp.  257,  453. 
Bennett.     Trans.  Medico-Chir.  Soc,  vol.  lxxi.  p.  139. 

(60)  Abscess  of  the  Testicle. 

Sheild.     Trans.  Medico-Chir.  Soc,  vol.  lxxiv.  p.  69. 

(61)  Torsion  of  the  Spermatic  Cord. 

Nicoladoni.     Arch.f.  klin.  Chir.,  vol.  xxxi.,  1885,  p.  178. 
Bryant.     Trans.  Medico-Chir.  Soc,  vol.  lxxv.  p.  247. 
Gilford  Nash.     St.  Barthol.  Hosp.  Rep.,  vol.  xxix.,  1893, 
p.  163. 


APPENDIX    OF    REFERENCES  527 

(61)  Torsion  of  the  Spermatic  Cord  (continued) — 

Johnson.     Annals  of  Surgery,  vol.  xix.  p.  530. 
Lauenstein.     Annals  of  Surgery,  vol.  xx.  p.  97. 
Owen.     Trans.  Med.  Soc,  vol.  xvii.  p.  61. 

(62)  Hydrocele. 

Sei'ournet.     Rev.  mens,  des  mal.  de  Venfance,  viii.,  1890,  p. 
"359. 

(63)  Ovarian  Tumours. 

Aldibert.     Ann.  de  Gyne'kol.,  1894,  vol.  xxxix.  p.  184. 
Thornton.   Trans.  Medico-Chir.  Soc,  vol.  lxx.  p.  41. 

(64)  Diseases  of  Bloodvessels  and  N^evi. 

Caesfield.    Prackt.   Aerzt.,  13,  1893,  quoted  in  Annals  of 

Surgery,  vol.  xviii.  p.  247. 
R.  W.  Parker.     Trans.  Clin.  Soc,  xix.,  1886,  279. 
Boing.     Deutsch.  vied.  Woch.,  1886,  p.  290. 

(65)  Blood  Tumours  of  the  Scalp. 

Cremer.     Rev.  de  Chir.,  vol.  vi.,  1886,  p.  527. 

(66)  Cavernous  Lymphangiomata. 

Stiles.     Edinburgh  Hosp.  Rep.,  i.  520. 
Thorburn.     Illustrated  Med.  News,  i.  146. 

(67)  Spina  Bifida. 

Report  of  a  Committee  of  the  Clinical  Society.     Trans. 

Clin.  Soc,  vol.  xviii.  p.  339. 
Broca.     Rev.  d'Orthopedie,  1895,  p.  38. 

(68)  Congenital  Cysts  arising  in  connection  with  the  Thyreo- 

glossal  Duct. 
Durham.     Trans.  Medico-Chir.  Soc,  vol.  lxxvii.  p.  199. 


ERRATA. 

Page  173,  line  7  from  bottom,  and  page  177,  line  11  from  bottom 
the  reference  number  14  should  be  16  in  each  case. 


INDEX 


Abbe,  Dr.,  on  renal  sarcoma,  416. 

Abercrombie,  Dr.,  on  acute  pharyn- 
geal tuberculosis,  285. 

Abdomen,  inflation  of,  in  intussus- 
ception, 397. 

Abdominal  ring,  varieties  of  exter- 
nal, in  children,  106. 

—  section,  378,  391. 

in  intussusception,  398,  400. 

Abscess,  acute  retropharyngeal,  25. 

—  acute,  in  septic  osteomyelitis,  33. 

—  cerebellar,  305,  307. 

—  cerebral,  305. 

—  chronic,  in  bone,  66. 
spinal,  73,  81,  82,  88. 

—  hip  treatment  of,  1  is. 

—  in  spinal  caries,  81,  82,  88. 

—  mastoid,  68,  303. 
treatment  of,  308. 

—  perinephric,  438. 

—  postpharyngeal,  see  Retropharyn- 

geal. 

—  psoas  calcified,  82. 
treatment  of,  88-92. 

—  residual,  82. 

—  retropharyngeal,  25,  237. 

—  temporo-sphenoidai,  305,  307,  328. 

—  testicular,  47s. 

—  thecal,  17. 

—  of  tongue,  2H">. 

Abscesses,  articular,  treatment  of, 
105. 

—  chronic,  in  tuberculosis  of   knee, 

treatment  of,  187. 

—  cold,  treatment  of,  88-92. 

—  in  hip  disease,  lis. 

—  in  joint  disease,  105,  1 1 2. 

—  in  joint  disi  -anient  of,  137. 
Acetabulum .  di  1 15. 
Actinomycosis,  28,  so,  . 

Acute  hydrocele,  485. 

—  infantile  paralysis,  193. 

—  necrosis.  30  ;  see  Osteomyelitis. 

—  osteomyi  1  i  is,  30. 

Adams,   Mr.   William,  on  congenital 

displacement  of  hip,  ^50. 
Adenoid  vegetal  ions,  279. 
ima  of  u  ague,  2>\i . 

—  rectal,  424, 

—  renal,  411. 


Adherent  labia,  489. 

Air  passages,  diseases  of,  332. 

foreign  bodies  in,  362. 

Albert,  Prof.,  on  arthrodesis,  195. 

Albuminuria  in  phimosis,  468. 

Aldibert,  Dr.,  on  hydronephrosis,  135. 

Allbutt,  Dr.  Clifford,  on  enlarged 
glands,  51. 

Allingham,  Mr.,  on  prolapse  of  rec- 
tum, 422. 

Ampere,  definition  of,  491. 

Amputation,  Syme's,  139. 

Anaesthesia  in  children,  3. 

Anal  fistula,  431. 

Anus,  fissure  of,  431. 

—  imperforate,  426. 
Anchyloglossa,  268. 
Anchylosis,  artificial,  195. 

—  of  jaw,  236. 

—  of  joints,  120,  124,  174. 

—  treatment  of,  123,  133. 
Aneurysm,  490. 

—  embolic,  190. 

—  intracranial,  490. 

—  intraorbital,  490. 

—  spontaneous.  490. 

—  traumatic,  490. 
Aneurysm  by  unustomosis,  490. 

—  cirsoid,  496. 

A  ageioma,  490  ;  si  e  Angioma. 
Angina  Ludovici,  20. 
Angioma,  L50,  266,  191. 

—  arterio-venous,  495. 

—  of  bone,  15o. 

—  of  scalp,  196. 

—  of  tongue,  206. 
Angio-sarcoma,  150,  193. 

ol  bone,  150. 
Angular  curvature  of  spine,  72. 
Ankle,  arthrectomy  of,  138. 

—  arthrodesis  of,  196, 197. 

—  tuberculosis  of,  137. 

A  uti'i'ior  poliomyelitis,  193. 
A  nt  ipyrin,  in  enuresis,  47  I. 

i.i  ic  treatment  of  burns,  5nl. 
Antiseptics     not   well    adapted    for 

children,  8. 
Antitoxin,  rash  after  inoculation  of, 
16. 
t  reatmenl  of  diphtfaeri  i  by,  335. 

M    M 


53° 


INDEX 


Antyllus  on  tracheotomy,  347. 
Aphthous  ulceration  of  tongue,  265. 
Appendicitis,  385. 
Appendicular  peritonitis,  385. 
Arm,  broken,  170. 

—  dislocation  of,  238. 

Arsdale,  Dr.  van,  on  subluxation  of 

bead  of  radius,  242. 
Arterio-vennus  angioma,  495. 
Artery,  ruptured  middle  meningeal, 

165. 
Arthralgia,  diphtheritic,  334. 
Arthrectomv,  109,  129. 

—  ankle,  138. 

—  elbow,  109. 
Arthritis,  97,  225. 

—  after  measles,  226. 

—  after  mumps,  226. 

—  chondro-,  230. 

—  diphtheritic,  226,  334. 

—  displacement  after,  245. 

—  dysenteric,  226. 

—  gbnorrhoeal,  127,  227. 

—  gummatous,  228. 

—  hemophilic,  232. 

—  infective,  35,  37,  226. 

—  non-tuberculous,  225. 

—  of  hip,  113. 

—  osteo-,  227. 

—  scarlatinal,  226,  227. 

—  secondary  to  osteomyelitis,  37. 

—  syphilitic,  228. 

—  traumatic,  225. 

—  tuberculous,  97. 

—  typhoidal,  226. 

—  variolous,  226. 
Arthrodesis,  195,  246. 
Arthrotomy,  174,  240. 
Asclepiades  on  tracheotomy,  347. 
Asphyxial       form      of       Raynaud's 

disease,  12. 
Aspiration  in  empyema,  368. 

—  in  pericarditis,  374. 

—  in  pleurisy,  372. 
Atresia  recti,  426. 
Atypical  excisions,  123. 
Auricles,  supernumerary,  290. 
Axial  rotation  of  testis,  481. 

Baker,  Mr.  Morrant,  on  imperforate 
anus,  429. 

on  whitlow,  49. 

Balano-posthitis,  468. 

Ball,  Dr.,  on  cultivation  of  diphtheri- 
tic micro-organisms,  333. 

—  on  intubation,  344. 

Ballance,  Mr.,  on  disease  of  the 
middle  ear,  311,312. 

—  on  thrombosis  of  lateral  sinus,  316. 
Ballantyne,    Dr.,     on    pre-auricular 

appendages,  290. 

Balzer,  Dr.,  on  appendicular  peri- 
tonitis, 385. 

Bandaging  in  children,  difficulties  of, 
9. 


Barbacci  on  appendicular  peritonitis, 

385. 
Barker,  Mr.,  on  cerebral  abscess,  311. 

—  on  excision  of  hip,  123. 

—  on  intussusception,  399. 
Barker's  treatment  of  cold  abscesses, 

88. 

—  flushing  scoop,  89. 

Barlow,  Dr.,  on  cervical  opistho- 
tonus, 318. 

—  on  scurvy,  198. 

Baruch,  Dr.,  on  enuresis,  474. 

Bar  well,  Mr.,  on  congenital  displace- 
ment of  hip,  248. 

Base-line  of  Beid,  311,  312,  326. 

Batteries,  varieties  of,  494. 

Battle,  Mr.,  on  dislocations  of  phal- 
anges, 243,  244. 

Beads  in  ear,  293. 

Beans  in  ear,  293. 

Behring,  Dr.,  on  diphtheria,  335. 

Belladonna,  in  treatment  of  enure- 
sis, 473. 

Benevieni  on  tracheotomy,  347. 

Bennett,  Mr.  W.  H.,  on  tuberculous 
testicle,  476. 

Bilharzia  a  cause  of  balano-posthitis, 
469. 

—  rectal  adenomata  caused  by,  425. 
Birmingham,  Prof.,  on  situation   of 

lateral  sinus,  310. 
Bismuth  nitrate,  treatment  of  burns 

by,  502. 
Bladder,  fistula  of,  518. 

—  hypertrophy  of,    after   circumci- 

sion, 468. 

—  sarcoma  of,  455,  518. 

—  stone  in,  447. 

—  tumours  of,  455. 

Blaxall,  Dr.,  on  pathology  of  otitis 

media,  295. 
Bleeders,  232. 
Bleeding,  arrest  of,  in  children,  4. 

—  after  circumcision,  466. 

—  after  cleft  palate  operations,  262. 

—  after  removal  of  tonsils,  278. 

—  after  tracheotomy,  355. 

—  transfusion  after,  5,  6. 
Blood  tumours  of  bone,  150. 
of  scalp,  496. 

Boils  and  their  treatment,  21. 
Bding,  Dr.,  on  nffivi,  492. 
Bone,  angeiomata  of,  150. 

—  blood  tumours  of,  150. 

—  caries  of,  see  Tuberculosis. 

—  chisel,  214. 

—  chronic  abscesses  in,  66. 

—  cuneiform  osteotomy  of,  214. 

—  decalcification  of,  154. 

—  dislocations  of,  235. 

—  epiphyseal  separation,  162. 

—  forcible  straightening  of,  209. 

—  fractures  of,  158. 

—  fragilitas  ossium,  161. 

—  greenstick  fracture  of,  158. 


INDEX 


DJ 


Bone,  injuries  of,  158. 

—  innocent  tumours  of,  146. 

—  linear  osteotomy  of,  211. 

—  malignant  tumours  of,  149. 

—  mastoid,  exploration  of,  308. 
osteomyelitis  of,  303, 304. 

—  na?vus  of,  150. 

—  necrosis  of,  11. 

due  to  syphilis,  151. 

—  osteoklasia  of,  209. 

—  osteopsathyrosis,  161. 

—  osteotomy  of,  211. 

—  petrous,  disease  of,  302,  315. 

—  rarefying  osteitis  due  to  syphilis, 

151. 

—  ricketty  changes  in,  201,  205,  208. 

—  sarcomata  of,  119. 

—  spontaneous  fractures  of,  160,  198, 

200. 

—  syphilitic  decalcification,  151. 
disease  of,  153. 

disease      distinguished       from 

tubercle,  154. 

—  temporal,  disease  of,  303. 

—  tuberculosis  of,  62. 

of  epiphyses,  66. 

of  shaft,  68. 

—  tuberculous  disease  distinguished 

from  syphilis,  154. 

—  tumours  of,  146. 

actinomycotic,  149. 

angeio-sarcoma,  150. 

blood,  150. 

chlorosarcoma,  149. 

chondromata,  146. 

cystic,  149. 

dentigerous,  149. 

endosteal  sarcoma,  149. 

—  —  epulis,  118,  151. 

exostoses,  147. 

green  sarcoma,  149. 

hydatid,  149. 

innocent,  116. 

lipomata,  148. 

malignant,  149. 

myeloid  sarcoma,  150. 

naevus,  150. 

ossifying  sarcoma,  152. 

parasitic,  119. 

parosteal  lipomata,  1  (8, 

periosteal  sarcoma,  151. 

sarcomatous,  119. 

Boric  acid,   treatment  of    burns  by, 

503. 
Bosworth,  Dr.,  on  adenoids,  282. 

—  on  nightmare,  274. 

Bottini,  Prof.,  on  anchylosis  of  jaws, 

237. 
Bouchut's   operation    of    intubation, 

340. 
Brain,  abscess  of,  305. 

—  exploration  of  middle  fossa,  309- 

312. 
of  ventricles  of.  326. 

—  fissure  of  Rolando,  position  of,  321. 


Brain,  fissure  of  Sylvius,  position  of, 
325. 

—  hydrocephalus,  acute,  325. 
chronic,  330. 

—  meningitis  of,  317. 

—  parieto-occipital  fissure  of,  325. 

—  puncture  of,  167,  325-330. 

—  thrombosis  of  sinuses,  313. 

—  topography  of,  324. 

—  tumours  of,  330. 

—  water  on,  325-330. 

Branchial  arches,  cysts  in  connection 

with,  513,  517. 
Bregma,  position  of,  321. 
Bretonneau  on  tracheotomy,  347. 
Brisement  force,  209. 
Broca,  Prof.,  on  exploration  of  lateral 

ventricles,  325. 
Broken  arm,  170. 

—  collar-bone,  168. 

—  forearm,  179. 

—  jaw,  168. 

—  knee-cap,  190. 

—  leg,  190. 

—  nose,  167. 

—  ribs,  183. 

—  skull,  164. 

—  thigh,  184. 

Bronchus,  foreign  bodies  in,  362. 

Brook,  Mr.,  on  tracheal  stenosis,  358. 

Brossard,  Dr.,  on  incomplete  *frac- 
tures,  181. 

Brothers,  Dr.,  on  empyema,  367. 

Brown  Buckminster,  Mr.,  on  con- 
genital displacement  of  hip,  250. 

—  Dr.  Dillon,  on  cultivation  of  diph- 

theritic micro-organisms,  332. 
Bryant,  Mr.,  on  ovariotomy,  488. 

—  on  prolapse  of  urethra,  460. 

—  on  torsion  of  spermatic  cord,  481. 
Bryant's  splint,  183. 

Bullar,  Dr.,  on  feeding  after  tracheo. 

tomy,  352. 
Burckhardt's  incision  for  opening  an 

acute    retropharyngeal    abscess, 

27. 
Burns,  after-treatment  of,  503. 

—  antiseptic  treatment  of,  501. 

—  bismuth  treatment  of,  502. 

—  boric  acid  treatment  of,  503. 

—  iodoform  treatment  of,  503. 

—  picric  acid  treatment,  of,  502. 

—  plastic  operations  after,  505. 

—  skin  grafting  in,  503. 

—  thiol  treatment  of,  502. 

—  treatment  by  baths,  503. 

—  treatment  of,  501. 
BurBSB,  tuberculosis  of,  139. 
Busch's,  Prof.,  treatment    for   frac- 
tures, 171. 

Caesfield,  Dr.,  on  naevi,  492. 
Cailltf,  Dr.,  on  removal  of  tonsils,  'J77. 
Calculi  vesical,  size  and  weight  of, 
419. 


532 


INDEX 


Calculus,  enuresis  in,  447,  472. 

—  preputial,  455. 

—  prostatic,  454. 

—  renal,  461. 

—  urethral,  455. 

—  vesical,  447. 

treatment  of,  449. 

Calomel  in  appendicular  peritonitis, 
394. 

—  fumigation  in  diphtheria,  336. 
Calvaria,  fractures  of,  164. 
Camphorated  naphthol,   8,   43,  56,  92, 

106,  129. 

formula  of,  9. 

injections  of,  381,  478. 

Cancellous  exostoses,  147. 
Cancer  of  lip,  263. 

—  of  rectum,  425. 
Cancrum  oris,  21. 
Capillary  nasvi,  491. 
Capitellum,  fracture  of,  178. 
Carcinoma,  adenoid,  425. 

—  of  lip,  263. 

—  ovarian,  487. 

—  recti,  425. 

Caries  of  bones,  see  Tuberculosis. 

—  cervical,  diagnosis  of,  80. 

—  dorsal,  diagnosis  of,  81. 

—  lumbar,  diagnosis  of,  81. 

—  necrotica,  artificial  production  of, 

66. 

—  sicca,  107. 

—  spinal,  wryneck  in,  221. 
Carpus,  tuberculosis  of,  70,  111. 
Carr,  Dr.  Walter,  on  tuberculous  dis- 
ease, 51,  52. 

Carr's  splint,  183,  192. 
Caseating  lymphatic  glands,  56. 

—  psoas  abscess,  82. 

Catheter,  Macewen's  tracheal,  357. 
Cavernous  lymphangioma,  497. 

—  nsevus.  493. 
Cellulitis,  19. 

Celsus  on  removal  of  tonsils,  276. 

—  on  subluxation  of   head  of  radius, 

242. 
Cephalhydrocele,  traumatic,  165. 
Cerebellar  abscess,  305-307. 
Cerebral  abscess,  305. 

—  hernia,  165. 

—  meningitis,  317. 

—  puncture,  167,  325,  330. 

—  sinus,  exploration  of,  310-312. 
thrombosis  of,  313. 

—  symptoms  ill-defined  after  fracture, 

165. 

—  tumours,  320,  330. 

Cerebrum,  exploration  of  ventricles 
of,  325. 

—  meningo-encephalocele,   treatment 

of,  331. 

—  tapping,  167. 

—  topography  of,  324. 
Cerumen  in  ear,  292. 
Cervical  hydrocele,  517. 


Cervical  caries,  diagnosis  of,  80. 

—  lymphatic     glands,   treatment   of 

enlarged,  55. 

—  opisthotonus,  318. 
Champneys,  Dr.,  on  tracheotomy,  350. 
Cheeks,  lupoid  ulceration  of,  59. 
Chemotaxis,  141. 

Chest,  exploration  of,  for  empyema, 
369. 

pericarditis,  374. 

pleurisy,  373. 

—  operations  upon,  368-374. 
Chewing-gum,  surgical  uses  of,  238. 
Cheyne,    Mr.  Watson,  on   treatment 

of  lupus,  61. 
Chiene's  incision  for  opening  an  acute 

retropharyngeal  abscess,  26. 
Children,  cerebro-cranial  topography 

in,  324. 

—  diagnosis  of  disease  in,  2. 

—  difficulties  in  bandaging,  9. 

—  dressings  for,  9. 

—  hernial  peculiarities  of,  405-411. 

—  peculiarities  of  stone  inbladder,447. 
in  kidney,  442. 

—  thermotaxic  peculiarities  of,  7,  421. 

—  trusses  for,  413-416. 
Children's  fractures,  peculiarities  of, 

158, 164. 

—  surgeon,  qualifications  of,  1. 
Chloro-sarcoma,  150,  446. 
Chondromata,  146. 
Chondro-arthritis,  230. 

osteitis,  154. 

Chronic  abscess,  treatment  of,  39,  88- 
92,  118,  145. 

—  spinal  abscess,  73,  82. 
Circumcision,  bleeding  after,  466. 

—  after  paraphimosis,  471. 

—  gangrene  after,  466. 

—  method  of  performing,  462. 

—  suppuration  after,  466. 

—  treatment  of  frsenum  in,  463. 
Cirsoid  aneurysm,  496. 
Clavicle,  fracture  of,  168. 

—  tuberculosis  of,  69. 
Cleft  palate,  258. 

haemorrhage  in,  262. 

nipple  for  feeding  children  with, 

258. 

sutures,  261. 

Club  foot,  treatment  of,  195. 

Clutton,  Mr.,  on  arthrectomy,  110,  130, 

139. 

—  on  syphilitic  synovitis,  230. 
Coates,  Mr.,  on  trusses,  413. 
Coccygeal  cysts,  514. 

Cold   abscesses,  treatment  of,  88-92, 

118. 
Collar-bone,  broken,  168. 
Colles'  fracture,  182. 
Colley,  Mr.  Davies,  on  cleft  palate, 

262. 
Collier  and  Pitts  on  tracheotomy,  353. 
Collodion  sublimate  for  nam,  492. 


INDEX 


533 


Colopexy,  123. 
Colotomy,  129. 
Compact  exostoses,  U7. 
Congenital  coccygeal  cysts,  514,  515. 

—  cysts,  treat  ,  61 1-517. 

—  deformities,  507. 

—  displacement  of  humerus,  252. 

—  dislocations,  2  16;  see  Displacements, 

congenital. 

—  giant  growth,  519. 

—  hydrocele,  186. 
of  the  neck,  517. 

—  hydronephrosis,   13.'. 

—  inguinal  hernia.  409. 

—  malformations,  507. 

—  overgrowth,  -r>h>. 

—  umbilical  hernia,  402. 
polypi,  518. 

Conner,  Dr.,  on  traumatic  meningo- 
cele, 165. 

Cooper,  Sir  Astley,  on  reduction  of 
dislocation  of  elbow,  210. 

—  on  subluxation  of  jaw,  236. 
Corbin,  Dr.,  on  diphtheria,  336. 
Corrosive  sublimate  collodion,  492. 
Costal  resection,  371. 
Counter-irritation  in  sacro-iliac   dis- 
ease, 113. 

Coupland,Dr.,on  double  empyema,372. 

Craniectomy,  331. 

Cranio-cerebral  topography,  324. 

Craniotabes,  syphilitic,  155,  156. 

Cranium,  fractures  of,  164. 

Cripps,  Mr.  Harrison,  on  imperforate 

anus,  430. 
Croft,  Mr.,  on  plastic  operations,  505. 
Cuneiform  osteotomy,  214. 
Curling,  Mr.,  on  imperforate  anus,  428. 
Curvature,  angulur,  of  spine,  72. 

—  lateral,  77,  216. 

—  ricketty,  78. 

Cystic  hygroma,  497,  199. 

—  tumours  of  bone,  149. 
Cystotomy,  suprapubic,  450,  459. 
Cysts,  congenital,  512. 

—  in  mouth,  263. 

—  pelvic,  517. 

—  sacro-coccygeal,  51  1. 

—  of  urachus,  518. 

Czermak,  Prof.,  on  adenoids,  279. 

Dactylitis,  tuberculous,  63,  70. 

Dalby's  artificial  nail,  281. 

Dana  on  cerebro-cranial  topography 
in  children,  321. 

Daniell's  cell,  in. 

Danz,  Signe  de,  396 

Deaver,  Dr.,  on  appendicular  perito- 
nitis, 385. 

Demme  on  tuberculous  testicle,  475. 

Deal  igi  n  rn  -  ■■  ■  - 1  ,  149. 

Dermoids,  512. 

—  in  month,  2i;i. 

—  ovarian,  487. 

—  of  testicle,  477,  481. 


Dermoids,  treatment  of,  513. 
Deutschmann  on  osteo-arthritis,  227. 
Diabetes,  enuresis  in,  472. 

—  baJano-posthitis  in,  469. 

—  fractures  in,  160. 
Dickinson,  Dr.,  on  empyemn,  367. 
Difficulties  in  bandaging  children,  9. 
Diffuse  osteomyelitis,  30. 
Diphtheria,  832. 

—  bacteriology  of,  332-335. 

—  balano-posthitis  in,  469. 

—  choice  of  operation  in,  33?. 

—  dyspnoea  of,  337. 

—  feeding  in,  314,  351. 

—  joint  affections  in,  331. 

—  treatment  by  antitoxin,  335. 
fumigation,  336. 

intubation,  34 1. 

tracheotomy,  347. 

—  wryneck  after,  221. 
Diphtheritic  arthritis,  226. 
Dislocation  of  arm,  238. 

—  backwards  of  radius  and  ulna,  239. 

—  forwards  of  radius  and  ulna,  241. 

—  congenital,  246. 

of  arm,  252. 

of  elbow,  252. 

of  knee,  250. 

of  hip,  216. 

of  humerus,  252. 

of  patella,  251. 

of  shoulder,  252. 

—  —  of  tibia,  250. 

—  of  fibula,  251. 

—  of  fingers,  243. 

—  of  hip,  215. 

—  of  lower  jaw,  236. 

—  of  nasal  septum,  235. 

—  of  penis,  471. 

—  of  radius,  241. 

—  passive,  of  fibula,  251. 
Dislocations,  235. 

—  of  phalanges,  213. 

—  secondary,  2 15. 

—  traumatic,  235. 
Displacement,  congenital,  246. 
of  arm,  252. 

of  patella,  251. 

of  shoulder,  252. 

Dorsal  caries,  diagnosis  of,  81. 
Dorsalis  pedis  artery,  neevi  of,  496. 
Double  empyema,  372. 

—  hip  disease,  125. 

Downie,  Dr.  Walker,  on  otitis  media, 

294,  297. 
Drainage  of  ulidornen,  380. 

—  of  cerebral  ventricles,  329. 

—  of  pleural  cavity,  870. 

—  suprapubic,  lf>  I,   l.V.i. 
Dressings  fur  children,  9. 

Dulles,  Dr.,  on  fractured  elbow,  177. 
Dunn's  Boshing  scoop,  89. 

Dllpin  I  n-:f     ex  isto    '-,  I  17. 

Durham,    Dr.    If.   E.,   on    congenital 
tumours,  513. 


534 


INDEX 


Dysenteric  arthritis,  226. 
Dyspeptic  nlceration  of  tongue,  265. 
Dyspnoea,  symptoms  of,  337. 

Ear,  beads  in,  293. 

—  beans  in,  293. 

—  cerumen  in,  292. 

—  eczema  of,  291,  296. 

—  epithelial  plugs  in,  292. 

—  foreign  bodies  in,  292. 

—  incision  of  drum,  298. 

—  insects  in,  293. 

—  lupus  of,  59. 

—  mastoid  osteomyelitis,  303. 

—  middle,  inflammation  of,  293. 
influenzal,  301. 

scarlatinal,  300. 

syphilitic,  301. 

tuberculous,  301. 

typhoidal,  301. 

—  otorrhcea,  293. 

—  peas  in,  293. 

—  pre-auricular  appendages,  290. 

—  supernumerary  auricles,  290. 

—  wax  in,  292. 

Ectopia  intestinalis,  402,  518. 

—  testis,  478. 

—  vesica1,  508. 
Eczema,  291,  296,  462,  469. 
Ekehorn  on  appendicular  peritonitis, 

385. 
Elbow,  arthrotomy  of,  240. 

—  disease  of,  109. 

—  dislocation  of,  238-243. 

—  excision  of,  110.  240. 

—  fractures  of.  173. 

—  secondary  displacement  of,  245. 

—  synovial  relations  of,  96. 

—  T-fracture  of,  176. 
Electrical  treatment  of  nasvi,  493. 

—  treatment  of  paralysis,  195. 

of  Raynaud's  disease,  13. 

Electrolysis  of  nsevi,  494. 

—  for  naso-pharyngeal  tumours,  288. 
Elefson,  Dr.,  on  broken  thigh,  188. 
Embolic  aneurysm,  490. 

—  tuberculous  sequestra,  66. 
Emphysema,  gangrenous,  23. 
Empyema,  365. 

—  aspiration  of,  368. 

—  cardiac,  373. 

—  double,  372. 

—  drainage  of,  368. 

—  exploration  of,  369. 

—  radical  cure  of,  371. 

—  spontaneous  opening  of,  368. 

—  treatment  of,  369. 

Emulsion  iodoform,  formula  for,  104, 
Encephalocele,  treatment  of,  331. 
Enchondromata,  146. 
Enchondroma  of  testis,  481. 
Endosteal  sarcoma  of  bone,  149,  150. 

differential  diagnosis,  64. 

Enlarged    lymphatic    glands,    treat- 
ment of,  53-57. 


Enlarged  tonsils,  273. 
Enterectomy,  399. 
Enuresis,  472. 

—  antipyrin  in,  474. 

—  astringents  in,  474. 

—  Baruch's  treatment  of,  474. 

—  cold  sound  in,  473. 

—  masturbation  associated  with,  473. 

—  nux  vomica  in,  474. 

—  treatment  of,  473. 
Epicondyles,  fractures  of,  177. 
Epididymitis,  478. 
Epilepsy,  enuresis  in,  472. 
Epiphyseal  changes  in  rickets,  204, 

205. 

—  changes  in  scurvy,  197,  198. 
Epiphysis  of  clavicle  separated,  170. 

—  femur  separated,  184. 

great  trochanter,  186. 

lower,  188. 

upper,  185. 

—  of    humerus— great    tuberosity  — 

separated,  172. 

—  of   humerus  —  lower  —  separated, 

174. 

—  of  humerus  —  upper  —  separated, 

171. 

—  of  olecranon,  separation  of,  179. 

—  of  radius,  separation  of  lower,  182. 
of  upper,  180. 

—  injury  to,  after  osteoklasia,  210. 

—  separations  of,  158,  163. 

—  separated,  dangers  of,  163. 

—  separation  of,  suppuration  after, 

163,  186,  190. 

—  synovial  relations  of,  96. 

—  syphilitic,  inflammation  of,  228. 

—  tibial  tubercle,  separation  of,  190. 

—  tuberculosis  of,  66. 
Epulis,  148. 

■ —  malignant,  150. 

—  sarcomatous,  150. 
Erasion  of  joints,  109, 129. 
Erysipelas,  18. 

—  a  cause  of  balano-posthitis,  469. 

—  neonatorum,  18. 
Evysipele  bronze,  24. 

Erythema  from  antitoxin  treatment, 
16. 

Eskridge,  Dr.,  on  nervous  symptom* 
in  vertebral  caries,  74. 

Esmarch,  Prof.,  on  anchylosis  of  jaws, 
237. 

Estlander's  operation,  372. 

Ethylate  of  sodium,  treatment  of 
nam  by,  492. 

Eustachian  tube,  method  of  inflating, 
298. 

Eve,  Mr.,  on  excision  of  wrist,  112. 

Exanthemata  a  cause  of  balano-pos- 
thitis, 4H9. 

—  as  a  cause  of  osteomyelitis,  31. 
of  septic  gangrene,  22,  23. 

—  dislocations  secondary  to,  245,  248. 
Excision,  intestinal,  399. 


INDEX 


535 


Excision  of  ankle,  138. 

—  of  elbow,  110,  111,  240. 

—  of  bip,  121. 

—  of  joints,  103,  110,  132. 

—  of  knee,  132. 

—  of  shoulder.  108. 

Excisions,  atypical,  110,  123,  129,  138. 
Exomphalos.  402. 
Exostoses,  1 17. 

—  intra-articular,  1 17. 
Exploration  of  cerebral  ventricles,  325. 
Extension  apparatus  for   short  leg, 

121. 

—  in  hip  disease,  method  of  applying, 

116. 

—  in  joint  disease,  method  of  apply- 

ing, 116. 
Extravasation  of  urine,  458,  461. 

Fabricius  on  tracheotomy,  317. 
Faecal  fistula,  51s. 

Pa  -bender  on  tuberculosis  of  ribs,  69. 
Feeding  after  intubation,  311. 

—  after  tracheotomy,  351. 

—  forced,  253,  351. 

—  nasal,  352. 

Felizet,  Dr.,  on  circumcision,  463. 

—  on  inguinal  hernia,  406,  409. 
Femur,  fracture  of,  184. 

—  intracapsular  fracture  of,  185. 

—  separation  of  epiphysis  of   groat 

trochanter,  186. 

lower,  188. 

upper,  185. 

Fenger,  Dr.,  on  surgery  of  ureter.  438. 
Fere\  Dr.,  on  inguinal  hernia,  400,  109. 
Fibro-angioma,  naso-pharyngeal,  286. 
Fibroma,  naso-pharyngeal,  236. 

—  of  tongue,  267. 
Fibula,  fracture  of,  191. 

—  passive  dislocations  of,  251. 
Fingers,  dislocation  of,  2H. 
Fischer,  Dr.,  on  cesophagotomy,  271. 
Fissure  of  aims,  431. 

Fistula,  faecal,  518. 

—  in  ano,  181. 

—  penile,  155. 

—  vesicoumbilical,  518. 
Flail  joints,  treatment  of,  195. 
Floating  kidneys,  111. 

rifludeil,  511. 
Fold  of  Venus,  106. 
Forced  feeding,  251,  351. 
Forcible    Straightening    of    ricketty 

bones,  209. 
Forearm,  fractures  of,  181. 
Foreign  bodies  in  air  passages,  362. 

—  in  ear,  292. 

—  in  nose,  288. 

—  in  oesophagus,  270. 
Foreskin,  inflammation  of,  4C9. 
Fouillehouze,  Dr.,  on  cranio-eerebral 

topography  in  children,  32-1. 
Foiirnier  on  subluxation  of  head  of 
radius,  242. 


Fowler,  Dr.  Ryersnn,  on  appendicular 

peritonitis,  336,  391,393. 
Fox,  Dr.  Colcott,  on  scurvy,  200. 
Fracture  of  capitellum,  178. 

—  clavicle,  168. 

—  Colles',  182. 

—  elbow,  173. 

—  epicondyles,  177. 

—  femur,  184. 

—  fibula,  Ml. 

—  humerus,  173. 

—  jaw,  168. 

—  metatarsal  bones,  192. 

—  nasal  bones,  167. 

—  non-union  after,  159. 

—  natella,  190. 

—  Pott's,  191. 

—  radius,  181. 

—  ribs,  183. 

—  spiral,  182. 

—  spontaneous,  in  ribs,  155. 

—  T,  of  elbow,  176. 

—  tibia,  191. 

—  ununited,  159. 
Fractures,  anchylosis  after,  174. 

—  greenstick,  158,  163. 169, 181, 185, 187. 

—  incomplete,  158,  181. 

—  intra-uterine,  162. 

—  multiple,  161. 

—  peculiarities  of.in  children,  158, 164. 

—  skull,  164-167. 

special  dangers  of,  in  children, 

165. 

—  spontaneous,  155,  160,  198,  200. 

—  subperiosteal,  158,  169,  181,  ]s">. 

—  supracondylar,  of  humerus,  176. 

—  treatment  of,  174. 

—  ununited  clavicle,  169. 
femur,  185. 

humerus,  178. 

tibia,  191. 

Fraenum  praeputii,  treatment  in  cir- 
cumcision, 463. 

Fragilitas  ossium,  161. 

Freitage  on  hernia,  113. 

Freyer,  Surgeon-Major,  on  lithola- 
paxy,  449. 

—  on  vesical  calculus,  113. 
Frontal  bone,  tuberculosis  of,  68. 
Fumigation  in  diphtheria,  336. 
Fungating  caries.  00. 
I'urneaux-Jordan's   hip   amputation, 

124. 
Furunculosis,  21. 

Gaillard,  Dr.,  on  congenital'  disloca- 
tions of  shoulder,  252. 

Gangrene  in  afterio-venous  angto- 
mata,  495. 

—  after  circumcision,  466. 

—  asphyxial  form  of  Raynaud's  dis- 

ease, 12. 

—  erysipelatous,  19. 

—  non-infective,  L0. 

—  of  prepuce,  470. 


53^ 


INDEX 


Gangrene  of  the  fauces  and  soft 
palate,  23. 

—  Raynaud's,  11. 

—  spontaneous,  11. 

—  symmetrical,  11. 

—  syncopic   form  of    Raynaud's  dis- 

ease, 12. 

—  traumatic,  11,  175,  189. 

—  typhoidal,  15. 
Gangrenous  emphysema,  23. 

Gay,  Dr.,  on  acute  pharyngeal  tuber- 
culosis, 285.| 

Gee,  Dr.  S.,  on  phagedena  and  septic 
gangrene,  21. 

—  on  cervical  opisthotonus,  318. 
Generative  organs,  male,  diseases  of, 

458-487. 

female,  487-489. 

Genu  valgum,  207. 

Gerster,  Prof.,  on  epididymitis,  478. 

Giant  growth,  519. 

Girls,  urethral  prolapse  in,  460. 

—  vesical  calculus  in,  452. 
sarcoma  in,  456. 

—  vulvitis  in,  488. 
Glands,  tuberculous,  53. 
Glandular  tumours  of  tongue,  267. 
Glioma,  cerebral,  330. 
Glossitis,  264. 

Glottis,  stenosis  of,  356. 
Godlee,  Mr.,  on  empyema,  369. 

—  on  fractures  of  skull,  164. 
Golding-Bird,Mr.,on  wryneck,  220,222. 
Gonorrhoea  a  causeof  ba'lano-posthitis, 

469. 

of  vulvo-vaginitis,  489. 

Gonorrhoeal  arthritis,  127,  227. 

Gooch's  splint,  173,  187. 

Good,  Mr.,  on  foreign  bodies  in  the 
air  passages,  363. 

Gottstein's  curette  for  removal  of 
adenoids,  283,  284. 

Gould,  Mr.  Pearce,  on  double  em- 
pyema, 372. 

—  on  umbilical  polypi,  518. 

Gout  a  cause  of  balano-posthitis,  469. 

Grafting  skin,  60,  503. 

Grant,  Dr.  Dundas,  on  inflation  of 
Eustachian  tubes,  298. 

Greenstick  fractures,  158,  168, 169, 181, 
185. 

Gubernaculum  testis,  attachments  of, 
478. 

Guerin,  Dr.  Jules,  on  congenital  dis- 
placements, 246. 

Gummatous  arthritis,  228. 

Gums,  lupus  of,  59. 

—  tumours  of,  148,  151. 
Gymnastics,  Swedish,  in  scoliosis,  219. 

Habershon,    Dr.,    on    feeding    after 

tracheotomy,  352. 
Hajmatoma,  perineal,  458. 
Hematuria,  426,  434,  442,  455. 
Haemophilia,  232. 


Hemophilic  arthritis,  232. 
Haemorrhage  after  circumcision,  466. 
Haemorrhage   after  removal  of   ton- 
sils, 278. 

—  after  tracheotomy,  355. 

—  arrest  of,  4. 

—  scorbutic,  198,  200. 

—  transfusion  after,  5. 
Hasmorrhagic  disease,  231. 
Hamilton,  Dr.,  on  subluxation  of  jaw, 

236. 

—  on  traumatic  dislocation  of  hip,  245. 
Hammond's  splint  for  broken  jaw,168. 
Hansemann,  Prof.,  on  diphtheria,  336. 
Harelip,  253. 

—  asphyxia  after,  257. 

—  dangers  in  operating  upon,  257. 

—  Kronlein's  suture  in,  256. 

—  treatment  of  premaxilla?  in,  256. 
Haward,   Mr.  Warrington,    on    mov- 
able and  floating  kidneys,  441. 

Head,  pneumatocele  of,  518. 
Head-swing  for  wryneck,  223. 
Heath,  Mr.  Christopher,  on  injury  of 

clavicle,  170. 
Heaton,  Mr.,  on  umbilical  cysts,  518. 
Heister  on  hernia,  413. 
Hernia,  abdominal,  401. 

—  cerebral,  165. 

—  complicated  by  undescended  testis, 

411,416,  420,479. 

—  congenital  inguinal,  410. 

—  cured  by  truss,  415. 

—  exomphalos,  402. 

—  funicular,  410. 

—  inguinal,  405. 

anatomical,  peculiarities  of,   in 

children,  406-409,  416. 

—  —  causes  of,  411. 

contents  of  sac,  412. 

defective  pillars  in,  407. 

differential  diagnosis  of,  412. 

radical  operation  for,  413,  416. 

spontaneous  cure  of,  412,  415. 

—  —  treatment  of,  palliative,  413. 
operative,  416. 

■  treatment  of  sac  in,  418. 

varieties  of  abdominal  ring    in 

children,  406-409. 
with    undescended    testis,  410, 

416,420. 

—  irreducible,  412. 

—  lumbar,  401. 

—  needle,  420. 

—  of  spinal  membranes,  507. 

—  omphalocele,  402. 

—  pleural,  365. 

—  pulmonary,  365. 

—  scrotal,  410. 

—  strangulated,  396,  401,  412. 
inguinal,  401. 

umbilical,  403. 

—  testis,  476. 

—  umbilical,  402. 

—  vaginal,  402. 


INDEX 


537 


Heubner,  Prof.,  on  diphtheria,  33G. 

—  on  intubation,  3 
Hip,  amputation  of,  124. 

—  atypical  excisions  of,  123. 

[genital  displacement  of,  248. 

—  disease,  79,  118  L26. 

abscess  in,  118. 

cause  of  pain  in,  114. 

cause  ot  wasting  iu,  Hi. 

diagnosis  of,  LIS. 

displacement  of  femur  in,  119. 

double,  126. 

—  —  night  screaming  in,  99, 119. 

operative  treatment,  121. 

osteotomy  in,  124. 

palliative  treatment,  121. 

—  —  the  management  of  lordosis  in, 

treatment  of,  116.  118. 

treatment  of  abscesses  in,  11  3. 

treatment  of  anchylosis  in,  123. 

when  cured,  115. 

—  dislocate  c     i ,  2  15,  246. 

—  excision  of,  121. 

—  extension  in,  116. 

—  hysterical,  11.5. 

—  obscure  injuries  about,  184. 

—  osteomyelitis  of,  116. 

—  secondary  displacement  of,  245. 

—  synovial  relations  of,  96. 
Hippocrates  on  subluxation  of  head 

of  radius,  2  12. 
Hirschberg,  Dr.,  on  lumbar  puncture, 

323. 
Historical,    Celsus     on    removal    of 

tonsils,  276. 

—  mastoid  exploration,  308. 

—  Maundeville,  Sir  John,  519. 

—  on  giant  growth,  519. 

—  Philoctetes,  illness  of,  43. 

—  radical  cure  for  hernia,  413. 

—  Bead,  Dr.,  on  tongue-tie,  268. 

—  Scott,  Sir  Walter,  illness  of,  194. 

—  Swift's  case,  325. 

—  tracheotomy,  ■',  17. 

—  tuberculous  testis,  475. 

Hoffa  on  congenital  di>placement  of 
hip,  25o. 

—  on  spondylitis,  72,  77. 

Holden,  Mr.,  landmarks  quoted,  239. 
Holmes,  Mr.,  on  hip  disease,  120. 

—  on  vaginal  hernia,  102. 
Horrocks'  method  of  transfusing,  6. 
Howse  on  arthrodesis,  L95. 

—  on  excision  of  joints,  1:^2,  136. 
Hulke,  Mr.,  on  nsevi,  193. 
Humerus,  congenital  displacement  of, 

252. 

—  fractures  of,  173. 

—  separation  of  epiphyses  of,  171,  172, 

171. 

—  supraci  ndj  lar,  fractures  of,  176. 
Humphrey,   Sir    George,  on    knock- 

.  207. 
Hunt,  Dr.  William,  on  preputial  cal- 
culus, 455. 


Hutchinson,  Mr.  Jonathan,  jun.,  on 
separated  epiphyses,  164,  171,  175, 
17s,  179,  181,  191. 

—  on   subluxation  of  head  of  radius, 

180,  212. 
Hutchinson,  Mr. Jonathan,  on  syphilis 

of  skull,  155. 
Hydatids  of  bone,  149. 

—  of  spine,  SO. 
Hydrocele,  485. 

—  of  the  neck,  517. 

—  treatment  by  excision,  487. 
injection,  487. 

puncture,  4S7. 

truss,  187. 

Hydrocephalic  cry,  320. 
Hydrocephalus,  fractures  in  cases  of, 

—  acute,  325.  [160. 

—  chronic,  330. 

—  in  spina  bifida,  511. 
Hydrogen  peroxide,  8,  353,  354,  393. 
Hydronephrosis,  acquired,  161. 

—  congenital,  432. 

—  traumatic,  433. 

Hydrops  articuli,  126,  127,  225. 
treatment  of,  129. 

—  of  ankle  very  rare,  137. 
Hygroma,  497,  499. 
Hyperesthesia,  75,  78,  115,  509. 
Hypertrichosis  in  spina  bifida,  609. 
Hypertrophy,  chronic,  of  tonsils,  273. 

—  of  pinna,  291. 

—  of  tongue,  266. 

Hypertrophic     pulmonary     osteoar- 
thropathy, 93. 
Hysterical  hip,  115. 

—  spine,  78. 

Idiocy,  331. 
Imperforate  anus,  426. 
Included  foetus,  514. 
Incontinence  of  urine,  172. 
Infantile  paralysis,  193. 
fract  lives  in,  160. 

—  scurvy,  197. 

infection  by  tubercle,  51,  140. 
Infective  ai  tin  it  is,  226. 

—  diseases,  non-tuberculous,  16. 
-  osteitis,  29. 

—  thrombosis,  190,  313. 
Inflammation,  laryngeal,  358. 
Inflation,  intestinal,  in    intussuscep- 
tion, 397. 

Influenza,  osteomyelitis  after,  31. 

—  otitis  alter,  301. 
Inguinal  hernia,  105. 

i  ts  in  ear,  293. 
intestinal  ob  traction,  acute,  394. 

chronic,  -too. 

intestine,  gangrenous,  treatment  of, 

—  rectal  prolapse,  422.  3>«i. 
1  otestines,  proti                 101. 

ectopia  of,  402 
[ntra-articular  fracture  of  capitellum, 

17s. 


538 


INDEX 


Intracapsular  fracture  of  femur,  185. 
Intracranial  aneurysms,  490. 

—  tumours,  330. 
Intraorbital  aneurysm,  490. 
Intra-uterine  fractures,  162. 
Intubation,  339-317,  358,  360. 

—  after  tracheotomy,  358. 

—  feeding  after,  344. 

■ —  introduction  of  tube,  341. 

—  removal  of  tube,  346. 

—  sequelae  of,  345. 
Intussusception,  394. 

—  chronic,  400. 

—  gangrenous  intestine  in,  treatment 

of,  399. 

—  inflation  in,  397. 

—  laparotomy  in,  398,  400. 

—  Signe  de  Danz,  396. 

—  taxis  in,  397. 

Iodoform  in  treatment  of  burns,  503. 

—  emulsion,  formula  for,  104. 
Irreducible  hernia.  412. 
Ivory  exostoses,  147. 

Jacobi,  Dr.,  on  diphtheria,  344. 

—  on  prolapse  of  rectum,  422. 
Jacobson,  Mr.,  on  arthrodesis,  195. 

—  on  dangers  of  harelip  operation,  257. 
James,  Dr.  A.,  on  effects  of  phimosis, 

468. 
Jasser  quoted,  308. 
Jaw,  anchylosis  of,  236. 

—  dislocation  of,  236. 

—  fracture  of,  168. 

—  subluxation  of,  236. 

Johnson,   Dr.   R.  W.,  on  torsion  of 

spermatic  cord,  481. 
Joint,  arthrotomy,  240. 

—  disease  of  hip,  113. 

of  knee,  126. 

of  sacro-iliac,  112. 

of  shoulder,  107. 

of  sterno-clavicular,  106. 

of  wrist,  111. 

triple  displacement  in,  126. 

—  diseases, treatment  of  sinuses  in, 137. 

—  operations  on  wrist,  196. 

Joints,  abscesses  in  connection  with 
disease  of,  118. 

—  abscesses,  treatment  of,  1.37. 

—  anchylosis  of,  124,  174. 

—  ankle,  arthrodesis  of,  197. 
disease  of,  137. 

—  arthrectomy  of,  129. 

—  arthrodesis  of,  195. 

—  artificial  anchylosis  of,  195. 

—  cause  of  wasting  in  disease  of,  114. 

—  changes  in  haemophilic,  233. 

—  congenital  displacements  of,  246. 

—  diphtheritic  inflammation  of,  334. 

—  diseases  of  elbow,  109. 

of  hip,  osteomyelitis  of,  115. 

—  dislocations  of,  236-252  ;    sec   Dis- 

locations. 

—  displacements  in,  245,  246. 


Joints,  erasion  of,  129. 

—  excision  of,  108,  110,  112, 132. 

—  flail,  treatment  of,  195,  196. 

—  gonorrhceal   inflammation  of,  127,. 

227. 

—  hydrops  of,  129,  225. 

—  hydrops  articuli,  126,  127,  225. 

—  inflammation  of,  225  ;  see  Arthritis. 

—  iodoform  injections  into,  104. 

—  knee,  arthrodesis  of,  196. 

—  knee,  Thomas'  splint  in,  128. 

—  Lannelongue's        treatment       for 

disease  of,  102. 

—  neuralgia  of,  334. 

—  night  screaming  in  disease  of  ,99,1 19. 
■ —  operation,  arthrectomy,  109,  129. 
arthrotomy,  240. 

erasion,  109. 

excision,  108,  110,  112,  132. 

on  ankle,  138. 

on  arthrodesis,  195. 

on  elbow,  109. 

on  hip,  121. 

on  jaw,  237. 

-on  knee,  129. 

on  shoulder,  108. 

—  paralytic  treatment  of,  194-197. 

—  pseudo-paralytic,  in  scurvy,  198. 
in  rickets,  205. 

-in  syphilis,  153. 

—  sacro-iliac  disease,  112. 

—  sclerogeny  in,  102. 

—  scorbutic,  198. 

—  secondary  displacements  of,  245. 

—  Senn's  treatment  for  disease  of,  104. 

—  subluxation  of  jaw,  236. 

—  subluxation  of  radius,  180,  212. 

—  synovial  membranes  of,  96. 

—  treatment  of  abscesses  in  disease 

of,  105,  118. 

—  tuberculosis  of,  97. 

—  wrist,  arthrodesis  of,  196. 

Jones,  Dr.  Lewis,  on  electrolysis  of 
nsevi,  493. 

—  Mr.  Robert,  on  arthrodesis,  195. 

—  on  spinal  caries,  77,  80,  81. 
Jugular  vein,  thrombosis  of,  313. 
Jullien  on  tuberculous  testicle,  475, 478. 

Kassel,  Dr.,  on  otitis  media,  294. 
Keegan,Brig.-SurgeonLieut.-Colonel, 

on  litholapaxy,  449. 
Keen,  Prof.,  on  aneurysm,  490. 

—  on  exploration  of  lateral  ventricles, 

325. 

—  on  hypertrophy  of  pinna,  291. 
Keetley,  Mr.,  on  imperforate  anus,  429. 
Keith,  Mr.,  on  litholapaxy,  449. 
Kettle-holder  splint,  173,  187. 
Kidney,  abscess  of,  438. 

—  calculus  of,  441. 

—  diseases  of,  432. 

—  wounds  of,  435. 
Kidneys,  floating,  444. 

—  hydronephrosis  of,  432. 


INDEX 


539 


Kidney,  movable,  ill. 

—  nephrolithotomy,  -14-1. 

—  pyonephrosis  of*  43S. 
after  circumcision,  463 

—  repair  (if,  436. 

—  rupture  of,  435. 

—  tuberculous,  410. 

—  tumours  of,  adenomata,  411. 
cystic,  415. 

dermoid,  445. 

fibromata,  441. 

rhabdomyosarcoma^,  415. 

sarcomata,  445,  44S. 

teratomata,  445. 

Klebs-Lomer  bacillus,  332,  335. 
Knee,  arthrodesis  of,  196. 

—  congenital  displacement  of,  250. 

—  disease  of,  120. 

—  secondary  displacement  of,  245. 

—  splint,  method  of  applying,  128. 
Thomas',  application  of,  128. 

—  synovial  relations  of,  90. 

—  tuberculosis  of,  126. 
Knock-knee,  207. 

Konig,  Prof.,  on  haemophilia,  234. 

—  on  tuberculous  peritonitis,  376. 
Korte  on  purulent  pericarditis,  374. 
Kossel  on  diphtheria,  335. 
Krouecker's  transfusion  fluid, formula 

for,  5. 
Kronlein's  suture  in  harelip,  256. 

Labia,  adherent,  489. 
Laminectomy,  81-88. 
Landerer's  formula  for    transfusion 

fluid,  5. 
Landmarks,  Mr.  Holden's,  quoted,  239. 
Lang-ton,    Mr.,    case    of     fragilitas 

ossium,  161. 
Lannelongue,  Prof.,  on  blood  tumours 

of  scalp,  196. 

—  sclerogeny,  102,  103,  250. 
Laparotomy,  378,  391. 

—  contra-indications  for,  380. 

—  for  chronic  intussusception,  400. 

—  in  intussusception,  39s   K)0. 
Laryngeal  ob-t  ructiim,  30u. 

—  stenosis,  symptoms  of,  337. 

—  treatment  of,  335-365. 
Larynx,  foreign  bodies  in,  302. 

—  inflammation  of,  358. 

—  intubation  of,  339-347,  358. 

—  necrosis  of,  359. 

—  new  growths  of,  360. 

—  scalds  of,  359. 

—  stenosis  of,  356. 

—  syphilitic  inflammation  of,  358. 

—  thyrotomy,  361. 

—  traumatic  inflammation  of,  358. 

—  tuberculous  inflammation  of,  358. 

—  ulceration  of,  359. 
Lateral  curvature,  78,  216. 
ricketty,  205,  210. 

—  sinus,  exploration  of"  810-312, 

—  ventricles,  exploration  of,  325. 


Lauenstein,  Dr.,  on  torsion  of  sper- 
matic cord,  482. 

Leclanche  battery,  494. 

Lee,  Dr.  Robert,  on  rickets,  204. 

Leg,  broken,  190. 

Leichtenstern  on  intussusception,  39 1. 

Linear  osteotomy,  211. 

Ling's  gymnastic  system  for  scoliosis, 
219. ' 

Lingual  abscess,  265. 

Dip,  cancer  of,  203. 

—  epithelioma  of,  263. 

—  malignant  disease  of,  263. 
Lipoma  of  tongue,  207. 
Lipomata,  parosteal,  1 18. 
Litholapaxy,  449. 
Lithotomy,  lateral,  151. 

—  suprapubic,  1">2. 
Lithotrites,  150. 
Lithotrity,  449. 

Lockwood,   Mr.   C.    B.,    on    inguinal 

hernia,  410,  419. 
Loewenberg's  curette  for  removal  of 

adenoids,  281. 
Long  bones,  tubercle  of,  60. 
Lordosis,  importance  of  overcoming, 

in  cases  of  hip  disease,  118. 

—  its  management,  118. 
Lorenz  on  scoliosis,  220. 

—  on  torticollis,  223. 

—  operation   in  congenital    displace- 

ment of  hip,  249. 

—  treatment  of  spinal  caries,  83. 
Lower  jaw,  fracture  of,  108. 

Lucas,    Mr.    Clement,    on    traumatic 

meningocele,  100. 
Ludwig  on  submaxillary  cellulitis,  20. 
Lumbar  caries,  diagnosis  of,  81. 

—  hernia,  401. 

—  puncture,  322. 
Lung,  hernia  of,  365. 
Lupoid  ulceration  of  ear,  59. 
of  gums,  59. 

of  tongue,  59. 

Lupus,  58. 

—  of  pharynx,  57,  286. 

—  of  tongue,  266. 

—  producing  general  tuberculosis,  59. 

—  skin  grafting  in,  00. 

—  use  of  sulphur  in,  60. 
Lymphadenitis,  tuberculous,  53. 
Lymphangiectasis,  497. 
Lymphangioma,  200,  mi,  197. 
Lymphatic  aSBVUS,  2iiii,  491,  197. 

Jfacbride,  Prof.,  on  cerebral,  abscess, 
306. 

Mcliurney,  Dr., on  appendicular  peri- 
tonitis, 391. 

McBurney'a  point,  387. 

Macewen,  Prof.,  on  cerebral  abscess, 
307,  308. 

—  on  laminectomy,  86. 
Macewen 's  hernia  needle,  419. 

—  osteotomy,  211. 


54o 


INDEX 


Macewen's  tracheal  catheter,  357. 
McFadyean,   Prof.,    on    tuberculous 

peritonitis,  374. 
Mackenzie's,  Sir   Morell,  styptic   for 

bleeding  from  tonsils,  279. 
Mackie,  Dr.,  on  Bilharzia,  425. 
Macrocheilia,  497. 
Macroglossia,  266,  497. 
Malar  bone,  tuberculosis  of,  69. 
Malaria,  wryneck  after,  221. 
Malformations  of  ear,  290. 

—  rectal,  42(5. 

Malignant  disease,  fractures  in,  160. 

—  epulis,  151. 

—  oedema ,  23. 
Malposition  of  testis,  478. 
Marchant,  Dr.,  quoted,  165,  424. 
Marsh,  Mr.  Howard,  on  differential 

diagnosis  of  tuberculous  osteitis,64. 

—  on  rectal  nasvus,  426. 

Mason's  treatment  of  broken  nose,  168. 
Massage,  oesophageal,  271. 
Mastin,  Dr.,  on  cranial  angioma,  496. 
Mastoid  antrum,  exploration  of,  308. 
relations  of,  310. 

—  bone,  disease  of,  303. 

—  indications  for  exploration  of,  308. 

—  osteomyelitis  of,  303. 

—  tuberculosis  of,  69,  314. 
Masturbation,  signs  of,  473. 
Maxilla  inferior,  dislocation  of,  236. 
Maxillary  bones,  tuberculosis  of,  69. 
Mears,  Dr.,  on  anchylosis  of   jaws, 

237,  238. 
Measles,  arthritis  after,  226. 

—  a  cause  of  balano-posthitis,  469. 

—  osteomyelitis  after,  31. 
Melsena,  425,  426. 

Membrana,  tympani  incision  of,  298. 
Meningeal  artery,  rupture  of,  165. 
Meningitis,  cerebral,  317. 

—  non-tuberculous,  317. 

—  simulated  by  otitis  media,  297. 

—  tuberculous,  319. 
Meningocele,  507,  510. 

—  traumatic,  165. 
Meningo-encephalocele, treatment  of, 

331. 

—  -myelocele,  507,  508,  510.  [336. 
Mercurial   fumigation  in  diphtheria, 
Metacarpal  bones,  epiphyseal  separa- 
tions of,  192. 

—  fracture  of,  191. 

Metatarsal  bones,  fractures  of,  192. 
Meyer,  Prof.,  on  adenoids,  279. 
Meyer's  ring-knife,  284. 
Miorocephalus,  331. 

—  a  cause  of,  155. 

Micturition,  peculiarities  of,  in  vesical 
calculus,  447. 

Middle  ear,  inflammation  of,  293. 

Millet,  Dr.,  on  vascular  supply  of 
testis,  483. 

Milk  as  a  source  of  tuberculous  in- 
fection, 61. 


Milliamperes,  195,  494. 

Monod,  Prof.,  on  hydronephrosis,  434. 

—  and  Trelat  on  giant  growth,  519. 
Morbus  coxae,  113  ;  see  Hip,  disease  of. 
Morgan,  Mr.  J.  H.,  on  litholapaxy,  452. 
Morton's  fluid,  injection  of,  511. 
Morvan's  disease,  44,  507,  509. 
Moullin,   Mr.   Mansell,   on  injury  to 

radins,  180. 

—  on  subluxation  of  head  of  radius, 

180,  242. 
Mouth,  cysts  of,  263. 
— ■  tuberculous  disease  of,  57,  285. 

—  wounds  of,  269. 
Movable  kidneys,  444. 

Mucous  membranes,  tuberculosis  of, 

57. 
Mumps,  arthritis  after,  226. 
Murdoch,  Dr.    Burn,    on    effects   of 

phimosis,  468. 
Murray,  Mr.R.  W.,  on  osteoklasia,  209. 
Miitter  lectures  quoted,  24. 
Myeloid  sarcoma  of  bone,  150. 
Myers,  Prof.,  on  spinal  caries,  77. 
Myotomy  in  hip  disease,  123. 
Myringotome,  299. 
Myringotomy,  298. 
Myxomata,  vesical,  455. 

Nasvus,  491. 

—  of  bone,  150. 

—  of  cerebral  meninges,  491. 

—  naso-pharyngeal,  286,  496. 

—  rectal,  426'. 
Na;vi,  arterial,  496. 

—  capillary,  491. 

—  cavernous,  493. 

—  degenerations  of.  493. 

—  lymphatic,  266,  491,  497. 

—  of  nasal  fossa?,  286,  496. 

—  of  tongue,  266,  491. 

—  pigmented,  492. 

—  port- wine  stains,  492. 
■ —  sarcomatous,  493. 

—  subcutaneous,  492. 

—  treatment  by  corrosive  sublimate 

collodion,  492. 

by  extirpation,  493. 

■ by  nitric  acid,  492. 

by  sodium  ethylate,  492. 

— ■  vascular,  491. 

—  venous,  492. 
Nfevo-sarcoma,  493. 

Nail,  artificial,  for  adenoids,  284. 
Naphthaline,  319,  378. 
Naphthol,  319,  378. 

—  camphorated,  43,  92,  129,  138,  381. 

—  —  formula  for,  9. 

injections  of,  381. 

Nasal  bones,  fracture  of,  167. 

—  fossas,  naevus  of,  496. 

—  septum,  dislocation  of,  235. 

Nash,     Mr.    Gifford,    on    torsion    of 

spermatic  cord,  481. 
Naso-pharyngeal  tumours,  286. 


INDEX 


541 


Nasopharynx,  chronic  inflammation 

of,  294 
Navel,  ruptured,  404. 

—  tumours  of,  518. 
Necrosis  of  bone,  total,  41. 

—  epiphyseal,  163. 

—  fractures  in,  160. 

—  laryngeal,  3 

—  syphilitic,  IS  l. 

—  tuberculous,  63,  31 1. 
Nephrectomy,  189,  146. 
Nephritis,  chronic,  enuresis  in,  472. 

—  in  phimosis,  468. 

—  tuberculous,  440. 
Nephrolithotomy,  Hi. 

New-born  children,  peritonitis  in,  384. 
Nicoladoni   on   torsion  of    spermatic 

cord,  181. 
Nightmare,  causes  of,  271. 
Night-enuresis,  472. 
— terrors,  280. 
— screaming,  99,  1 19. 
Nitric  acid,  treatment  of  nsevi  by,492. 
Nodes,  Parrot's,  155. 

—  soft,  155. 

—  typhoidal,  40. 
Noma,  81. 
Non-infective  gangrene,  10. 

—  -suppurative  osteomyelitis,  40. 

—  -tuberculous  infective  diseases,  16. 

—  -tuberculous  meningitis,  317. 
Northrup,  Dr.,  on  diphtheria,  336. 
Nose,  dislocation  of  septum  of,  235. 

—  fracture  of,  167. 

—  lupoid  ulceration  of,  59. 

—  noevus  of  nasal  fossse,  496. 

—  Rouge's  operation  on,  288. 

—  tumours  of,  286-288. 
Nuhn,  glands  of,  263. 

Obstruction,  acute  intestinal,  394. 

—  chronic  intestinal,  400. 
Obturator,  lithotrity,  450. 

—  for  tracheal  stenosis,  358. 
O'Connor  extension  apparatus,  121. 
( tdontomata,  1 10. 

O'Dwvei  tdon   of    intubation, 

839-347,358. 
(Edema,  malignant,  23. 
(Esophagotomy,  271. 
(Esopha^u  ,  bodies  in,  270. 

—  stricture  of,  272. 
Ohm,  definition  1  if,  I'M. 
Olecranon,    separated    epiphysis   of, 

179. 
Omphalocele,  402. 
Operation,  atypical  excisions,  110,  123, 

129,  L38. 

—  cerebral  puncture,  325,  330. 

—  colopexy,  123. 

—  enterectomy,  399. 
Kstlander's,  871. 

—  Furneaux  -  Jordan's     amputation, 

121. 

—  in  empyema,  371. 


[  ion  in  pericarditis,  374. 

—  in  pleurisy,  373. 

—  inrlatiouof  bowel,  3  17. 

—  injection  of  Morton's  fluid,  510. 

—  intubation  of  larynx,  339-317. 

—  laparotomy,  378,  391. 
in  intussusception,  398. 

—  litholapaxy,  1  IS. 

—  lithotrity,  151. 
nephrectomy,  139,  146. 

—  nephrolithotomy,  in. 
-  orchidopexy,  180. 

—  plastic,  60  264,  268 

—  radical,  Ei  c  hernia,  404,  416. 

—  resection  of  ribs,  371. 

—  Rouge's,  288. 

—  spina  bifida,  510. 

—  Thiersch's.  60,  503. 

—  thyrotomy,  361. 

—  tonsillotomy,  27r.. 

—  tracheotomy,  317,  348. 

—  trephining    for    lateral  ventricles, 

325. 

—  trephining,  mastoid,  309. 

—  vermiform  appendix,  removal    of, 

3:12. 
Operations,  after-treatment  of,  8. 

—  precautions      to    be     adopted    in 

children,  3. 
Opisthotonus,  cervical,  318. 
Orbital  nam,  496. 
Orchidopexy,  480. 
Orchitis,  tuberculous,  175. 
Ord,  Dr.  U'allis,  quoted,  198,  322. 
Ossifying  sarcoma,  127,  152. 
Osteitis,  infective,  29. 

—  rarefying  syphilitic,  154. 

—  Syphilitic,  15  1. 

—  tuberculous,  62. 
Osteo-arthritis,  227. 

-arthropathy,  pulmonary,  93. 
Osteoclast,  210. 
eoklasia,  209. 
myelitis,  acute,  30. 
— ■  course  oi  abscess  in,  33. 

ol'  femur,   1  1  '<■ 

—  of  hip,  115. 

—  mastoid,  303. 

—  non-suppurative,  40. 
sequela  of,  41. 

—  syphilitic,  in  children,  151. 
in  infants,  153. 

tuberculous,  66. 

—  typhoidal,  10. 
■  -  vertebral,  80. 
Osteopsathyrosis,  161. 
Osti  osarcoma,  152. 

1 1  teotome,  211,  214. 
1 1  teotomy,  211. 

—  chisel,  214. 

—  cuneiform,  21 1. 
linear,  211. 

—  of  the  neck  Of  the  femur,  121. 

—  subtrochanteric     in     hip     disease, 

124. 


542 


INDEX 


Otitis,  influenzal,  301. 

—  media,  293,  315. 

bacteriology  of,  295. 

method  of  inflating  Eustachian 

tube  in,  298. 
simulating  meningitis,  297. 

—  scai-latinal,  300. 

—  syphilitic,  301. 

—  tuberculous,  301. 

—  typhoidal,  301. 
Otorrhcea,  293. 
Ovarian  tumours,  487. 

Owen,  Mr.  Edmund,  on  arthrectomy, 
130. 

—  on  acute  osteomyelitis,  34. 

—  on  axial  rotation  of  testis,  481. 

—  on  enuresis,  473,  474. 

Page,  Mr.  Fred,  quoted,  430,  437. 
Paget,  Mr.  Stephen,  on  nsfivi,  493. 
Painless  whitlow,  44. 
Palate,  gangrene  of,  23. 
Pantin,  Mr.,  on  empyema,  369. 
Papilloma,  laryngeal,  360. 

—  of  tongue,  267. 
Papillomata,  vesical,  455. 
Paralysis,  false,  153,  198,  205. 

—  infantile,  193. 

—  in  spina  bifida,  509. 

Paralytic  joints,  treatment  of,  193-197. 

—  symptoms  in  spinal  caries,  74,  82. 
Paraphimosis,  470. 

—  circumcision  after,  471. 
Paraplegia  in  spinal  caries,  75,  82. 
Parasitic  cysts  of  bone,  149. 
Parietal  bone,  tuberculosis  of,  68. 
Parieto-occipital  fissure,  position  of, 

325. 
Park,    Dr.    Roswell,    on    malignant 

oedema,  24. 
Parker,  Mr.  C.  A.,  on  adenoids,  280. 

—  Mr.  R.  W.,  on  aneurysm,  490. 

—  on  na?vi,  491. 

—  quoted,  20,338. 
Paronychia,  43. 
Parosteal  lipomata,  148. 
Parrot's  nodes,  155,  156. 
Passive  dislocation  of  fibula,  251. 

—  haemorrhages,  231. 

—  movement  in  joint  disease,  108,  111, 

177. 
Patella,  congenital  displacement  of, 
251. 

—  fracture  of,  190. 

Pathology  of  infective  osteomyelitis, 
30. 

—  of  tubercle,  52,  63,  101,  140. 
Pelvic  cysts,  514-517. 
Penis,  dislocation  of,  471. 

—  fistula  of,  455. 

—  gangrene  of,  470. 

Penrose,  Dr.,  on  effects  of  removing 

tonsils,  276. 
Pericarditis,  purulent,  373. 
Perinephric  abscess,  438. 


Periosteal  sarcoma,  151. 
Periostitis  albuminosa,  40. 

—  infective,  30  ;  see  Osteomyelitis. 

—  ossifying,  39. 

—  suppurative,  33,  39. 
Peritoneal  abscess,  392. 
Peritoneum,  relations  in  imperforate 

anus,  428. 

—  tuberculosis  of,  375. 
Peritonitis,  appendicular,  385. 

—  due  to  pneumococcus,  383. 

—  in  the  new-born,  384. 

—  recurrent,  390. 

—  relapsing,  390. 

—  suppurative,  402. 

Peroxide  of  hydrogen,  use  of,  8,  353, 
354,  393. 

Petersen's  bag,  453. 

Petersen,  Dr.,  on  intracranial  tu- 
mours, 330. 

Petit,  J.  L.,  on  mastoid  disease,  308. 

Petit's  triangle,  hernia  through,  401. 

Petrous  bone,  disease  of,  302. 

Peyer,  Prof.,  on  enuresis,  473. 

Phageda?na  and  septic  gangrene,  21. 

Phagocytosis,  141. 

Phalanges,  chondromata  of,  146. 

—  dislocation  of,  243. 

—  exostoses  of,  147. 

—  necrosis  of,  44,  46. 

—  septic  osteomyelitis  of,  44,  46. 

—  syphilitic  disease  of,  154. 

—  tuberculous  osteomyelitis  of,  70. 
Pharyngeal   tonsils,  hypertrophy  of, 

279. 

Pharyngitis  sicca,  adenoids  a  cause 
of,  281. 

Pharynx,  acute  tuberculous  inflam- 
mation of,  285. 

—  lupus  of,  57,  286. 

—  scalds  of,  359. 

—  tuberculosis  of,  285. 

—  tuberculous  disease  of,  57. 
Philoctetes,  his  malady,  43. 
Phimosis,  461. 

—  accidents  from,  461. 

—  albuminuria  in,  4H8. 

—  circumcision  in,  462. 

—  dilation  of,  461. 

—  low  sp.  gr.  of  urine  in,  468. 
Phosphaturia,  fractures  in,  160. 
Pick,  Mr.  Pickering,  quoted,  32,   143, 

179,  200. 
Picric  acid,  treatment  of  burns  by,  502. 
Pigmented  naevi,  491. 
Pinna  of  ear  hypertrophy,  291. 
Pitte,  Mr.,  on  tracheotomy,  353,  358, 

361. 
Plaster  case,  how  to  make,  212. 
Plastic  operations,  6«,  254,  258,  505. 
Pleura,  cervical  hernia  of,  365. 

—  operations  on,  368-374. 
Pleurisy,  treatment  of,  373. 
Plug,  tracheal,  358. 
Pneumatocele  cranii,  518. 


INDEX 


543 


Pneumoeoccus  in  meningitis,  317. 

—  in  peritonitis,  383. 
Pneumonia,  osteomyelitis  after,  81. 
Polikier,  Dr.,  on  oesophageal  massage, 

Poliomyelitis,  anterior,  193. 
Politzer,  method   of  inflating  Eusta- 
chian tube,  298. 

—  Prof.,  on  otitis  media,  295. 
Pollard,  Mr.  Bilton,  on  ectopic  testis, 

480. 

on  excision  of  hip,  122. 

Polypi,  rectal,    121. 

—  umbilical,  618. 
Port-wine  stains,  492. 
Posthitis,  468. 
Post-nasal  growths,  279. 

—  pharyngeal  abscess,  acute,  25. 

abscess,  chronic,  81. 

Pott's  disease  of  the  spine,  72. 

—  fracture,  191. 

Powell,  Dr.  Douglas,  case  of  actino- 
mycosis, 28. 

Praemaxilla,  treatment  of,  in  harelip, 
256. 

Preputial  calculi,  455. 

Pre-auricular  appendages,  290. 

Pregnancy,  precocious,  487. 

Prepuce,  dilatation  of,  461. 

—  gangrene  of,  47<>. 

—  inflammation  of,  468. 

Prescott    and    Goldthwait,   Drs.,    on 

diphtheria,  346. 
Pringle,  Dr.,  case  of  actinomycosis, 

28. 
Prolapse  of  rectum,  422. 

—  urethra,  460. 
Prostatic  calculi,  454. 
Pseudo-paralysis  in  scurvy,  198. 
ricketty,  205. 

syphilitic,  153. 

Psoas  abscess,  treatment  of,   82,  88- 

92. 
Pulmonary  osteo-arthropathy,  93. 
Puncture  of  vertebral  column,  322. 
Purulent  pericarditis,  373. 
Pyasmia,  17, 

—  after   epiphyseal  separation,    163, 

186,  190 

—  of  lateral  sums,  313. 

Pye,  Mr.  Walter,  on  osteoklasia,  209. 
Pyelitis,  calculous,  443. 

—  enuresis  in,   17-. 
Pyelo- nephritis,  4W. 
Pyonephrosis,  138. 
Pyo-pericardinm,  373. 
I'    "salpinx,   Ins. 
Pyothorax,  305. 

Quarter-evil,  or  Hausch-brand,  24. 
Quincke,  Dr.,  on  lumbar  puncture, 
322. 

Rachitis,  203. 

Radical  operation  for  empyema,  371. 


Radical  operation  for  hydrocele,  487. 

for  inguinal  hernia,  116. 

for  nsevi,  493. 

for  spina  bifida,  511. 

for  umbilical  hei  ma  ,  104. 

Radius  and  ulna,  backward  disloca- 
tion of,  239. 

—  dislocation  of,  211. 

—  epiphyseal  separation  of,  180,  182. 

—  forward  dislocation  of,  I'll. 

—  fracture  of,  181. 

—  subluxation  of  head  of,  180,  242. 
Ranula,  26.'i. 

Rarefaction  of  bone,  43,  63,  68,  70. 
tying  syphilitic  osteitis,  I    i. 
Rasch,  Prof.,  on  otitis  media,  293. 
Rash  after  treatment  with  antitoxin, 

16. 
Rattcl,  Dr.,  on  otitis  media,  299. 
Ray  fungus,  28,  80,  1  19. 
Raynaud's  disease,  asphyrial  form, 12. 

syncopic  form,  12. 

Read,  Dr.  Alexander,  on  tongue-tie, 

268. 
Rectum,  adenomata  Bilharzia,  425. 

multiple,  425. 

single,  424. 

—  atresia  of,  426. 

—  cancer  of,  425. 

—  dilatation  of,  430. 

—  malformations  of,  426. 

—  nsevi  of,  126. 

—  prolapse,  422. 
Recurrent  peritonitis,  390. 

Reeves,  Mr.,  on  treatment  of  spinal 
caries,  83. 

Reid,  Prof.,  on  cranio-cerebral  topo- 
graphy, 326. 

Relapsing  peritonitis,  390. 

Renal  calculus,  111. 

■ enuresis  in,  472. 

Residual  abscess,  82. 

Host,  in  joint  disease,  10*. 

Retention  of  urine,  470,  515. 

Retro-pharyngeal  abscess,  25, 81,  287. 

Rheumatic  spine,  77. 

Hiioumatism,  infective,  35. 

Rhinolith,  288. 

Ribs,  fracture  of,  183. 

—  resection  of,  37 1 . 

—  ricketty  fracture  of,  184. 

—  spontaneous  fracture   of,  1T>5. 

—  syphilitic  fracture  of,  1  B  t 

—  traumatic  fracture  of,  184. 

—  tuberculosis  of,  69. 

Richardiere  on  osteoarthritis,.  227. 
Rickets,  203. 

—  forcible  straightening  of  bones  in, 

209. 

—  OHteoklasia  in,  209. 
Ricketty  pseudo-paralysis,  205. 

spine,  78,  205,  216. 
Ridlon,    Dr.,   on   double   hip  disease, 

125. 
on  spinal  caries,  77. 


544 


INDEX 


Ring-knife,  Meyer's,  231. 
Rolando,  fissure  of,  its  position,  324. 
Rose,  Prof.,  of  Berlin,  on  cleft  palate, 
259. 

—  Prof.  William,  of  London,  on  cleft 

palate,  260,  261. 
Rotation  of  testis,  481. 
Rouge's  operation,  283. 
Rcra.gb.ton,  Mr.  Edmund,  case  of,  150. 
Routh,  Dr.  Amand,  on  vulvo- vaginitis, 

499. 
Roux,  Prof.,  on  diphtheria,  33G. 
Ruault,  Dr.,  on  removal  of  tonsils,  278. 
Rupture,  see  Hernia,  401. 
Ruptured  urethra,  458. 

Sacro-coccygeal  cysts,  51 1. 
Sacro-iliac  disease,  79,  112. 

counter-irritation  in,  113. 

Saddle-back,  248. 

Sakharoff,    Prof.,  on    cultivation   of 

diphtheritic  micro-organisms,  333. 
Santi,  Mr.  de,  on  tonsillar  bleeding, 

278. 
Santvoord,   Dr.   van,  on  subluxation 

of  head  of  radius,  242. 
Saprffimia,  16. 
Sarcoma  of  bladder,  455,  518. 

—  of  bone,  119. 

—  cerebral,  330. 

—  in  children,  differential  diagnosis, 

64. 

—  endosteal,  differential  diagnosis  of, 

64. 

—  fractures  in  cases  of,  160. 

—  lingual,  268. 

—  nsevoid,  493. 

—  naso-pharyngeal,  236,  288. 

—  ossifying,  127,  152. 

—  ovarian,  487. 

—  periosteal,  151. 

—  of  spine,  80. 

—  of  testis,  477,  480. 

method  of  secondary  infection 

in,  481. 

—  of  vagina,  488. 

—  vesical,  455,  518. 

Sayre,  Prof.,  on  hip  disease,  115. 
Sayre's  treatment  for  fractured  cla- 

'  vicle,  169. 
Scalds  of  larynx  and  pharynx,  359. 

—  laryngeal,  treatment  of,  360. 

—  treatment  of,  501. 
Scalp,  blood  tumours  of,  496. 
Scapula,  tuberculosis  of,  69. 
Scarlatinal  arthritis,  226,  227. 

—  otitis,  300. 

Scarlet    fever,    balano-posthitis   in, 
469. 

—  hydrocele  in,  485. 

—  osteomyelitis  afrer,  31. 

—  wryneck  after,  221. 
Schmalfuss  on  tuberculosis  of  ribs,  69. 
Schwartze,     Prof.,    on   mastoid  dis- 
ease, 308. 


Sciopodes,  519. 
Sclerogeny,  102,  251 
Sclerosis  of  bone,  43,  154,  156. 
Scoliosis,  216. 

—  torsion  in,  217. 

Scott,  Sir  Walter,  illness  of,  194. 
Scurvy,  197. 

—  rickets,  197. 
Sebaceous  cysts,  513. 

Senn,  Prof.,  on  sclerogeny,  104. 

—  suprapubic  lithotomy,  454. 
Separation  of  epiphyses,  162. 
Septic  gangrene,  21. 

—  osteomyelitis,  30. 

—  poisoning,  symptoms  of,  16,  34. 
Septicasmia,  16. 

Septum  nasi,  dislocation  of,  235. 

—  tuberculous  disease  of,  57. 
Sequestra,    central     tuberculous,    in 

bone,  68. 

—  embolic,  tuberculous,  66. 

—  treatment  of,  42. 
Sermesius  on  hernia,  413. 

Serum,  treatment  of  diphtheria  by, 

335. 
Sheaths  of  tendons  in  forearm,  45. 

tuberculosis  of,  57. 

Shoulder,  disease  of,  107. 

—  dislocation  of,  233,  252. 

—  secondary  displacements  of,  245. 

—  synovial  relations  of,  96. 
Signe  de  Danz,  396. 

Sinus  lateral,  exploration  of,  310-312. 

—  longitudinal,  thrombosis  of,  313. 

—  prajcervicalis,  tumours    connected 

with,  512. 
Sinuses,  treatment  of,  in  bone,  137. 
Skin-grafting,  method  of,  60,  503. 
Skin,  tuberculosis  of,  58. 
Skull,  syphilitic  disease  of,  155. 
■ —  fractures  of,  164,  167. 

—  synostosis  of,  155. 

—  trephining,  309,  321,  324,  329. 

—  tuberculosis  of,  68. 
Smallpox,  arthritis  after,  226. 
Smith,  Mr.  R.,  on  congenital  displace- 
ments, 246. 

Smith,  Mr.  Thos.,  a  case  of,  148. 

—  on  cleft  palate,  261. 

—  on  foreign  bodies   in  the  air  pas- 

sages, 363. 
Snoring,  cause  of,  in  adenoids,  230. 
Sodium  ethylate,  treatment  of  nsevi 

by,  492. 
Soft  nodes,  155. 

—  palate,  gangrene  of,  23. 
Sonnenberg,     Dr.,   on  pneumatocele 

cranii,  519. 

Southam,   Mr.,  on   suprapubic  litho- 
tomy, 454. 

Spermatic  cord,  torsion  of,  481. 

Spicer,  Mr.  Holmes,  on  scurvy,  198. 

—  Dr.  Scanes,  on  adenoids,  281. 
Spina  bifida,  44,  76,  402,  507. 
enuresis  in,  472. 


INDEX 


545 


Spina  bifida  occulta,  508,  509. 
radical  operation  for,  511. 

—  ventosa,  63,  08,  7". 
Spinal  abscess,  73,  81,  82. 
treatment  of,  88-92. 

—  actinomycosis,  80. 

—  caries,  abscess  in,  81,  82. 

associated  with  tuberculous  tes- 
tis, 470. 

enuresis  in,  472. 

wryneck  in,  221. 

—  column,  puncture  of,  322. 
Spine,  actinomycosis  of,  80. 

—  caries  of,  diagnosis  of  scat,  80. 

—  curvature  of,  angular,  72. 
lateral,  216. 

—  differential  diagnosis  in  disease  of, 

77. 

—  hydatids  of,  80. 

—  hysterical,  78. 

—  lateral  curvature  in  caries  of,  73. 

—  nervous  symptoms  in  tuberculous 

disease  of,  74,  82. 

—  osteomyelitis  of,  80. 

—  Pott's  disease,  72. 

—  rheumatic,  77. 

—  ricketty,  78. 

—  sarcoma  of,  80. 

—  syphilitic,  80,  151. 

—  typhoidal,  79. 
Spiral  fracture,  182. 
Splint.  Bryant's,  188. 

—  Carr's,  183,  192. 

—  for  wryneck,  222-224. 

—  Gooch's,  173,  187. 

—  Hammond's,  for  broken  jaw,  168. 

—  Howse's,  136. 

—  Mason's,  for  broken  nose,  168. 

—  plaster,  preparation  of,  122,  212. 

—  Thomas'  hip,  122,  186 

knee,  127. 

Spondylitis,  72  ;  see  Spine. 
Spontaneous  aneurysm,  490. 

—  fracture  of  rilis,  155. 

—  fractures,  155,  160,  198,  200. 

—  gangrene,  11. 

Staveley,  Mr.  \V.  H.  C,  quoted,  164, 

340,3  k),  503. 
Steavenson,  Dr.,  on  naevi,  493. 
Stenosis,  laryngeal,  symptoms  of,  337. 

—  treatment  of,  335-360. 

—  of  trachea,  356. 
Sterno-clavicular  joint,  disease  of,  106. 

—  -mastoid,  tenotomy  of,  222. 
Sternum,  tuberculosis  of,  69. 
Stiles,  Mr.  Harold, quoted, 4©7. 

i-er's  battery,  106, 
Stone  in  bladder,  417. 
--  in  kidney,  411 . 

—  in  prepuce,  466. 

—  in  prostate,  164. 

—  in  urethra,  166 

Strangula  a,  396,  401,  103,  02. 

—  testis,  i si. 

—  umbilical  hernia,  103. 


Stricture  of  oesophagus,  272. 
Stromeyer's  cushion,  175. 
Sturrock,  Mr.,  quoted,  164. 
Subcutaneous  na?vi,  192. 
Subluxation  of  jaw,  236. 

—  of  radial  head,  180,  212. 
Submaxillary  cellulitis,  19. 
Subperiosteal  fractures,  158,  169,  181, 

185. 

Subtrochanteric  osteotomy  in  hip  dis- 
ease, 124. 

Sulphur,  treatment  of  lupus  by,  60. 

.Supernumerary  auricles,  290. 

Suppurating  lymphatic  glands,  55,56. 

Suppuration  after  separated  epiphy- 
ses, 163. 

—  in  mastoid,  308. 
Supracondylar  fractures  of  humerus, 

176. 
Suprapubic  cystotomy,  456,  459. 

—  lithotomy,  452. 
Surgical  tuberculosis,  51. 
Sutton,  Mr.  Bland,  quoted,  290,  512. 
Sutures  in  cleft  palate,  method  of  in- 
serting, 261. 

Swain,   Mr.,  on  anchylosis  of   jaws, 

237. 
Swedish  gymnastics  in  scoliosis,  219. 
Swift,  Dean,  325. 
Sylvius'  fissure,  situation  of,  325. 
Syme's  amputation,  139. 
Symmetrical  gangrene,  11. 
Syncopic  form  of  Raynaud's  disease, 

12. 
Synostosis  of  skull,  155. 
Synovial  membranes  of  joints,  96. 

—  sheaths  in  forearm,  15. 
Synovitis,  gummatous,  228. 

—  tuberculous,  98. 
Syphilis  of  skull,  155. 

—  of  tongue,  265. 
Syphilitic  arthritis,  228. 

—  chondro-arthritis,  230. 

—  craniotabes,  166. 

—  disease  of  bone,  153. 

—  laryngitis,  358. 

—  osteitis,  154. 

—  osteomyelitis,  153. 

—  otitis,  301. 

—  spine,  80. 

—  testicle,  477. 

Syringo-myelia,  U,  76,  507,  609. 
Syringo-myelocele,  507-510. 

T-fracture  of  elbow,  176. 

Talipes  in  connection  with  infantile 
p:i  ralysis,  I'.U. 

—  in  conneci  ion  with  spina  bifida,  608. 

—  treatment  of,  L96. 

Tampon  canula,  31s,  :i(il . 
Tarsus,  tuberculosis  of,  137. 
Taxis  in  intussusception,  396. 
Taylor's  1 1  race  for  spinal  ciricH,  H5. 

Taylor,  Dr.,  on  intussusception,  398. 
Tea  le,  Mr.  Pridgin,  quoted,  63. 

N   N 


546 


INDEX 


Telangiectasis,  493. 
Temporo-sphenoidal  abscess,  305,307. 
Tendon  sheaths,  tuberculosis  of,  57. 

in  the  forearm,  45. 

Tenotomy  in  hip  disease,  123. 

—  in  congenital  displacement  of  hip, 

249. 

—  of  sterno-rnastoid,  22*. 

—  in  talipes,  195. 
Teratoma,  445,  514. 
Testicle,  abscess  of,  478. 

—  acute  strangulation  of,  481. 

—  atrophy  of,  476. 

—  axial  rotation  of,  481. 

—  carcinoma  of,  480. 

—  dermoid  cysts  of,  477,  484. 

—  displaced,  478. 

—  ectopia  femoralis,  479. 
perinealis,  478. 

—  ectopic,  478. 

—  enchondroma  of,  481. 

—  gubernaculum  of,  478. 

—  hernia  of,  476. 

—  innocent  tumours  of,  481. 

—  malignant  tumours  of,  480. 

—  orchidopexy,  480. 

—  syphilitic,  477. 

—  tuberculous,  475,  478. 

—  undescended,  410,  416,  420,  478. 
Thecal  abscess,  47. 
Thermometric  indications  sometimes 

of  little  value  in  children,  7,  421. 
Thiersch's  method   of   skin-grafting, 

60,  503. 
Thigh  broken,  184. 
Thiol,  treatment  of  burns  by,  502. 
Thomas'  double  hip  splint,  113,   122, 

125. 

—  knee  splint,   method  of  applying, 

128. 

—  single  hip  splint,  121,  186. 
Thomas,  Mr.,  on  harelip,  255. 
Thoracoplasty,  371. 

Thorax,  exploration  of,  in  empyema, 
369. 

—  in  pericarditis,  374. 

—  in  pleurisy,  373. 

Thorburn,  Mr.,  on  laminectomy,  85. 
Thrombosis  of  cerebral  sinuses,  313. 

—  infective,  190. 

—  of  mastoid  vein,  315. 

—  venous,  495. 
Thyreo-glossal  duct,  264. 

tumours  in  connection  with,  512. 

Thyroid  lingual  tumours,  267. 
Thyrotomy,  361. 

Tibia,  tubercle  of,  separation  of  lower 
epiphysis,  190. 

upper  epiphysis,  190. 

Tongue,  abscess  of,  265. 

—  adenoma  of,  267. 

—  anchyloglossa,  268. 

—  aphthous  ulcers  of,  265. 

—  carcinoma  of,  268. 

—  diseases  of,  264. 


Tongue,  dyspeptic  ulcers  of,  265. 

—  glandular  tumours  of,  267. 

—  inflammation  of,  264. 

—  injuries  of,  264. 

—  lipoma  of,  267. 

—  lupus  of,  59,  266. 

—  microglossia,  266. 

—  mucous  patches  of,  265. 

—  papillomata  of,  267. 

—  sarcoma  of,  268. 

—  soft  fibroma  of,  267. 

—  syphilis  of,  265. 

—  thyroid  tumours  of,  267. 

—  -tie,  268. 

—  ulcers  of,  265. 

Tonsil,  hypertrophy  of    pharyngeal, 

279. 
Tonsillitis,  chronic,  273. 
Tonsillotomes,  276. 
Tonsils,  chronic  enlargement  of,  273. 

—  chronic  hypertrophy  of,  281. 

—  methods  of  removing.  276-278. 

—  tuberculous  disease  of,  57. 
Tordeus  on  appendicular  peritonitis , 

385. 
Torsion  producing  fracture,  182. 
epiphyseal  separation,  188. 

—  of  spermatic  cord,  481. 
Torticollis,  80,  220,  221. 

—  tenotomy  in,  222. 

Total  necrosis  of  bone,  cause  of,  41. 
Townsend,  Dr.,  on  passive    haemor- 
rhage, 231. 
Toxines,  diphtheritic,  334. 
Tracheal  catheter,  357. 

—  stenosis,  treatment  of,  356. 
Tracheotomy,  after-treatnieut  of,  351. 

—  catheterisation  after,  357. 

—  dangers  of,  354. 

—  dilator,  355,  356. 

—  emphysema  after,  350. 

—  feeding  after,  352. 

—  for   foreign    bodies    in    the     air 

passages,  363. 

—  haemorrhage  after,  355. 

—  indications  for,  347. 

—  infection  during,  355. 

—  operation  of,  348. 

—  plug  for  use  after,  358. 

—  stenosis  after,  356. 

—  tube,  care  of,  354. 

removal  of,  355. 

Transfusion,  5. 

—  directions  for,  6. 
Traumatic  aneurysm,  490. 

—  arthritis,  225. 

—  cephalhydrocele,  165. 

—  gangrene,  11. 

—  hydronephrosis,  433. 

—  meningocele,  165. 

Tr^lat,  Dr.,  on  laryngeal  stenosis,  357. 

—  and  Monod  on  giant  growth,  £19. 
Trendelenburg's  operatiug  table,  391. 

—  position,  391,  446,  451,  452. 

—  tampon  canula,  348,  361. 


INDEX 


547 


Trendelenburg's  tampon  tube,  318. 
Trephining   for  lateral  ventricles  of 
brain,  325. 

—  mastoid  process,  309. 

—  skull,  309,  321,  324,  329. 

Treves,   Mr.,   on   arrest  of  bleeding, 

278. 
Triple  displacement  in  joint  disease, 

126. 
Trochanter  of  femur,  separation   of, 

186. 
Trophic  changes  in  hip  disease,  114. 

in  spinal  disease,  75. 

Trousseau  on  tracheotomy,  3 17. 
Truss  for  spina  bifida,  510. 
Trusses,  401,  413. 
Tubby,  Mr.,  quoted,  164,  186,  188. 
Tubercle     of     tibia,     separation    of, 

190. 
Tuberculosis  of  ankle,  137. 

—  distinguished     from     syphilis    in 
bone,  154. 

—  enuresis  in,  172. 

—  inoculation  of,  58. 

—  of  bone,  62,  66. 

—  of  bursa?,  139. 
— ■  of  carpus,  70. 

—  of  elbow,  109. 

—  of  epiphyses,  66. 

—  of  hip,  113. 

—  of  kidney,  4W. 

—  of  knee,  126. 

—  of  larynx,  358. 

—  of  the  long  hones,  66. 

—  of  lymphatic  glands,  53. 

—  of  mastoid,  69,301,  314. 

—  of  middle  ear,  301. 

—  of  mouth,  57. 

—  of  mucous  membranes,  57. 

—  of  palate,  57. 

—  of  peritoneum,  375. 

—  of  pharvnx,  57,  285. 

—  of  ribs,  69. 

—  of  scapula,  69. 

—  of  septum  nasi,  57. 

—  Of  shafts  of  bones,  68. 

—  of  shoulder,  107. 

—  of  skin,  5s. 

—  of  skull,  68. 

—  of  spine,  72. 

—  of  sterno-clavicular  joint,  100. 

—  of  sternum,  69. 

—  of  tarsus,  70. 

—  of  tendon  sheaths,  57. 

—  of  testicle,  475. 

—  of  tongue,  266. 

—  of  tonsils,  57. 

—  pathology  of,  52,63,  101, 141. 

—  pharyngeal,  57,  286. 

—  produced  from  lupus,  59. 

—  8acro-iliac,  112. 

—  simple    and    mixed    infection    in, 

63. 

—  surgical,  ".I . 

—  synovial,  98. 


Tuberculosis,  vertebral,  72. 
Tuberculous  dactylitis,  63,  70. 

—  epididymitis,  478. 

—  infection,  61. 

—  lymphadenitis,  53. 

—  meningitis,  319. 

—  osteitis,  62. 

—  osteomyelitis,  66. 

—  otitis,  301. 

Tuberosity    of   humerus,    separated, 

172. 
Tumor  albus,  98,  106,  109,  127. 
Tumours,  adenomata,  267,  121,  445. 

—  of  bladder,  455. 

—  of  bone,  146. 

—  laryngeal,  360. 

—  myxoma,  455. 

—  of  naso-pharynx,  286. 

—  ovarian,  487. 

—  papilloma,  455. 

—  pneumatocele  cranii,  518. 

—  renal,  444. 

—  rhabdomyomata,  415,  511. 

—  sarcoma,  64,  149,  455. 

—  teratoma,  514. 

—  of  tongue,  267. 

Tympanic    membrane,     incision    of, 

298. 
Typhotdal  arthritis,  226. 

—  gangrene,  15. 

—  osteomyelitis,  40. 

—  otitis,  301. 

—  spine,  79. 

—  wryneck,  221. 

Ulceration,   lupoid,   of   pharynx,   57, 
285. 

—  tubercular,  of  pharynx,  285. 
Ulcers,  aphthous,  26.">. 

—  dyspeptic,  265. 

—  lupoid,  266. 

—  of  tongue,  265. 

—  tuberculous,  of  tongue,  266. 

Ulna  and  radius,   backward  disloca- 
tion of,  239, 

—  forward  dislocation  of,  241. 
separated  olecranon,  179. 

Umbilical  fistula,  51S. 

—  hernia,  402. 

radical  oure  of,  UH. 

—  polypi,  518. 

Undescended  testis,  410,  416,  420,  478. 
Ungual  phalanx,  exostosis  of ,  147. 
Union  by  first  intention  common  in 

children,  5. 
Ununited  fracture,  159,  16  9,  178,  185, 

191. 
Urachus,  abnormalities  of,  618. 
Ureter,  surgery  of,  138. 
Ureters,  rapture  of,  nr. 

Urethra,  prolapse  of,  460. 

—  rupture  of,  458. 
Urethral  calculi,  165. 

Uric  acid  diathesis  a  cause  of  balano- 
posthitis,  109, 


54S 


INDEX 


Urine,  extravasation  of,  458,  461. 

—  incontinence  of,  472. 

—  in  spina  bifida,  509. 

—  low  sp.  gr.  in  phimosis,  its  import, 

468. 

—  retention  of,  470,  515. 

—  suppression  of,  after  circumcision, 

468. 
Uvula,  method  of  repairing  clefts  in, 
260. 

Vagina,  sarcoma,  of,  488. 
Vaginal  hernia,  402. 
Vaginitis,  489. 
Variola,  arthritis  after,  226. 
Vascular  naevi,  491. 
Vas  deferens,  size  of,  in  infants,  418. 
Veins,  alterations  of,  in  telangiecta- 
sis, 493. 

—  ligature  of,  for  pysemic  thrombosis, 

18,  190,  315. 

—  mastoid,  thrombosis  of,  315. 

—  thrombosis  of,  190,  313. 
Ventricles,    exploration  of  cerebral, 

325. 
Venous  nasvi,  492. 

—  thrombosis,  495. 
Venus,  fold  of,  406. 

Vermiform  appendix,     inflammation 
of,  385. 

removal  of,  392. 

Verneuil  oncolopexy,  424. 

—  on  differential  diagnosis  of  tuber- 

culous osteitis,  64. 
Vertebrae,  72;  see  Spine. 
Vertebra?,  rheumatism  of,  77. 

—  scoliosis  of,  216. 

—  syphilitic  disease  of,  80,  154. 
Vertebral  caries,  72. 

—  column,  puncture  of,  322. 
Vesical  calculus,  447. 

enuresis  in,  472. 

treatment  of,  449. 

Villate,  liqueur  de,  formula  for,  103. 

Vitello-intestinal  duct,  518. 

Vocal  cords,  tumours  of,  360. 

Volt,  definition  of,  494. 

Von  Tienhoven  on  enuresis,  474. 

Vulvitis,  488. 

Vulvo-vaginitis,  489. 

Walsham,  Mr.,  on  dislocation  of  sep- 
tum nasi,  235. 


Walsharn,  Mr,  on  litholapaxy,  449. 

—  on  naso-pharyngeal  tumours,  288. 
Washbourn,  Dr.,  on  diphtheria,  336. 
Wasting  in  arthritis,  cause  of,  114. 
Water  on  the  brain,  325,  330. 
Waterhouse,  Mr.,  a  case  of,  144. 

—  on  tuberculous  meningitis,  322. 
Wedge  osteotomy,  214. 
Weight-extension,  amount  of,  in  chil- 
dren, 116. 

Weinberg's  apparatus  for  wryneck, 
224. 

Wells,  Sir  Spencer,  on  tuberculous 
peritonitis,  376* 

Wernher,  Dr., on  pneumatocele  cranii, 
519. 

Wernicke,  Prof.,  on  puncture  of  late- 
ral ventricles,  325. 

Whitlow,  43. 

Whitman,  Dr.  Royal,  on  intracapsular 
fracture  of  femur,  185. 

Whooping  cough,  hernia  after,  404, 
411,  415. 

—  osteomyelitis  after,  31. 
Widenmann,  Prof.,  on  giant  growth, 

519. 
Winiwater,  von,  Prof.,  on  arthrodesis, 

196. 
Woodhead.  Dr.  Sims,  on  tuberculous 

infection,  51,  375. 
Woollen  truss,  413. 
Wounds,  after-treatment  of  ch  ildren's, 

8. 

—  of  mouth,  269. 
Wrenching  joints,  123. 

Wright,  Prof.  A.  E.,  on  haemophilia, 
233. 

—  Mr.,  on  arthrectomy,  130. 

—  on  dangers  of  harelip  operation, 

257. 
Wrist,  arthrodesis  of,  196. 

—  disease  of,  111. 
Wryneck,  80,  220. 

—  in  spinal  caries,  diagnosis  of,  221. 
Wynter,  Dr.  Essex,  on  lumbar  punc- 
ture, 322. 

Zenner,  Dr.,  on  exploration  of  lateral 

ventricles,  325. 
Ziemssen,  Prof .,  on  lumbar  puncture, 

322. 
Zinc  chloride,  43,  67,  87,  102,  108,  122, 

131,  135,  137,  138. 


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Nervous  Diseases 14 


SUBJECT.  PAGE 

Nose 1 20 

Nursing 15 

Obstetrics 16 

Ophthalmology 9 

Osteology  (see  Anatomy) 3 

Pathology 16 

Pharmacy 16 

Physical  Diagnosis 17 

Physical  Training  (see  Miscel- 
laneous)     14 

Physiology  18 

Poisons  (see  Toxicology) 13 

Popular  Medicine 10 

Practice  of  Medicine 18 

Prescription-  Books 18 

Railroad  Injuries  (see  Nervous 

Diseases) 14 

Refraction  (see  Eye) 9 

Rheumatism  10 

Sanitary  Science 11 

Skin 19 

Spectacles  (see  Eye) 9 

Spine  (see  Nervous  Diseases)  14 
Stomach  (see  Miscellaneous)...  14 

Students'  Compends 22,  23 

Surgery  and  Surg.  Diseases...  19 

Syphilis 21 

Technological  Books 4 

Temperature  Charts 6 

Therapeutics 12 

Throat  20 

Toxicology 13 

Tumors  (see  Surgery) 19 

U.  S.  Pharmacopoeia 16 

Urinary  Organs 20 

Urine 20 

Venereal  Diseases 21 

Veterinary  Medicine 21 

Visiting  Lists,  Physicians'. 

(Send for  Special  Circular.) 
Water  Analysis  (see  Chemis- 
try)   11 

Women,  Diseases  of. 21 


'The  prices  as  given  in  this  Catalogue  are  net.  Cloth 
binding,  unless  otherwise  specified.  No  discount  can  be 
allowed  under  any  circumstances.  Any  book  will  be  sent, 
postpaid,  upon  receipt  of  advertised  price. 


SUBJECT   CATALOGUE   OF   MEDICAL   BOOKS. 


&g-  All  books  are  bound  in  eloth,  unless  otherwise  speci- 
fied.   All  prices  are  net. 

ANATOMY. 

MORRIS.  Text-Book  of  Anatomy.  791  Illus.,  214  of  which  are 
printed  in  colors.  Clo.,  £6.00;   Lea.,  £7.00  ;  Half  Russia,  $8.00. 

"  Taken  as  a  whole,  we  have  no  hesitation  in  according  very  high 
praise  to  this  work.  It  will  rank,  we  believe,  with  the  leading  Anato- 
mies. The  illustrations  are  handsome  and  the  printing  is  good."— 
Boston  Medical  and  Surgical  Journal. 

Handsome  Circular  of  Morris,  with  sample  pages  and  colored  illus- 
trations, will  be  sent  free  to  any  address. 

CAMPBELL.  Outlines  for  Dissection.  Prepared  for  Use  with 
"  Morris's  Anatomy"  by  the  Demonstrator  of  Anatomy  at  the  Uni- 
versity of  Michigan.  J1.00 

HEATH.  Practical  Anatomy.  A  Manual  of  Dissections.  8th 
Edition.     300  Illustrations.  $4.25 

HOLDEN.  Anatomy.  A  Manual  of  the  Dissections  of  the  Human 
Body.  6th  Edition.  Carefully  Revised  by  A.  Hewson,  m.d.,  De- 
monstrator of  Anatomy,  Jefferson  Medical  College,  Philadelphia. 
311  Illustrations.  Leather,  $3.00 

HOLDEN.  Human  Osteology.  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the  Muscles. 
The  General  and  Microscopical  Structure  of  Bone  and  its  Develop- 
ment.   With  Lithographic  Plates  and  numerous  lllus.    7th  Ed.     #5.25 

HOLDEN.     Landmarks.     Medical  and  Surgical.     4th  Ed.       $1.00 

MACALISTER.  Human  Anatomy.  Systematic  and  Topograph- 
ical, including  the  Embryology,  Histology,  and  Morphology  of  Man. 
With  Special  Reference  to  the  Requirements  of  Practical  Surgery  and 
Medicine.     816  Illustrations,  400  of  which  are  original. 

Cloth,  $5.00;  Leather,  $6. 00 

MARSHALL.  Physiological  Diagrams.  Life  Size,  Colored. 
Eleven  Life-Size  Diagrams  (each  seven  feet  by  three  feet  seven 
inches).     Designed  for  Demonstration  before  the  Class. 

In  Sheets,  Unmounted,  $40.00;  Backed  with  Muslin  and  Mounted 
on  Rollers,  $60.00;  Ditto,  Spring  Rollers,  in  Handsome  Walnut  Wall 
Map  Case  (send  for  special  circular),  $100.00;  Single  Plates — Sheets, 
85.00;  Mounted,  $7.50.  Explanatory  Key,  .50.  Descriptive  circu- 
lar upon  application. 

POTTER.    Compend  of  Anatomy,  Including  Visceral  Anatomy. 

5th    Edition.     16   Lithographed  Plates    and  117  other. Illustrations. 

.80;  Interleaved,  $1.25 
WILSON.     Human  Anatomy,     nth  Edition.   429  Illustrations,  26 

Colored  Plates,  and  a  Glossary  of  Terms.  $5.00 

WINDLE.  Surface  Anatomy  and  Landmarks.  Colored  and 
other  Illustrations.  $1.00 

ANESTHETICS. 

BUXTON.  On  Anesthetics.  3d  Edition.  Illustrated.  In  Press.- 
TURNBULL.  Artificial  Anesthesia.  The  Advantages  and 
Accidents  of;  Its  Employment  in  the  Treatment  of  Disease  ;  Modes 
of  Administration;  Considering  their  Relative  Risks;  Tests  of 
Purity;  Treatment  of  Asphyxia;  Spasms  of  the  Glottis;  Syncope, 
etc.    4th  Edition,  Revised.     54  Illustrations,    fust  Ready.        $2.50 


SUBJECT  CATALOGUE. 


BRAIN  AND  INSANITY. 

BLACKBURN.     A  Manual  of  Autopsies.     Designed  for  the  Use 

of  Hospitals  for  the  Insane  and  other  Public  Institutions.     Ten  full- 

'    page  Plates  and  other  Illustrations.  $1 .25 

GOWERS.     Diagnosis  of  Diseases  of  the  Brain.     2d  Edition. 

Illustrated.  $1.50 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and 
Functions  of.     Numerous  Illustrations.  J2.50 

IRELAND.  Mental  Affections  of  Children.  Idiocy,  Imbecility, 
Insanity,  etc.  Nearly  Ready. 

LEWIS  (BEVAN).  Mental  Diseases.  A  Text-Book  Having 
Special  Reference  to  the  Pathological  Aspects  of  Insanity.  18  Litho- 
graphic Plates  and  other  Illustrations.     New  Edition.  In  Press. 

MANN.  Manual  of  Psychological  Medicine  and  Allied 
Nervous  Diseases.  Their  Diagnosis,  Pathology,  Prognosis,  and 
Treatment,  including  their  Medico-Legal  Aspects  ;  with  chapter  on 
Expert  Testimony,  and  an  Abstract  of  the  Laws  Relating  to  the 
Insane  in  all  the  States  of  the  Union.     Illustrated.  $3.00 

REGIS.  Mental  Medicine.  Authorized  Translation  by  H.  M. 
Bannister,  m.d.  $2.00 

STEARNS.  Mental  Diseases.  Designed  especially  for  Medical 
Students  and  General  Practitioners.  With  a  Digest  of  Laws  of  the 
various  States  Relating  to  Care  of  Insane.     Illustrated. 

Cloth,  $2.75;  Sheep,  $3.25 

TUKE.  Dictionary  of  Psychological  Medicine.  Giving  the 
Definition,  Etymology,  and  Symptoms  of  the  Terms  used  in  Medical 
Psychology,  with  the  Symptoms,  Pathology,  and  Treatment  of  the 
Recognized  Forms  of  Mental  Disorders,  together  with  the  Law  of 
Lunacy  in  Great  Britain  and  Ireland.     Two  volumes.  £10.00 

WOOD,  H.  C.    Brain  and  Overwork.  .40 

CHEMISTRY  AND  TECHNOLOGY. 

Special  Catalogue  of  Chemical  Books  sent  free  upon  application. 

ALLEN.  Commercial  Organic  Analysis.  A  Treatise  on  the 
Modes  of  Assaying  the  Various  Organic  Chemicals  and  Products 
Employed  in  the  Arts,  Manufactures,  Medicine,  etc.,  with  concise 
methods  for  the  Detection  of  Impurities,  Adulterations,  etc.  2d  Ed. 
Vol.  I,  Vol.  II,  Vol.  Ill,  Part  I.  These  volumes  cannot  be  had. 
Vol.  Ill,  Part  II.  The  Amins.  Pyridin  and  its  Hydrozins  and 
Derivatives.  The  Antipyretics,  etc.  Vegetable  Alkaloids,  Tea, 
Coffee,  Cocoa,  etc.  $4- 50 

Vol.  Ill,  Part  III.  Animal  Bases,  Animal  Acids,  Cyanogen  Com- 
pounds, Proteids,  etc.  $4-5° 
Vol.  Ill,  Part  IV.    The  Proteids  and  Albuminoids.             In  Press. 

ALLEN.  Chemical  Analysis  of  Albuminous  and  Diabetic 
Urine.     Illustrated.  J2.25 

BARTLEY.  Medical  and  Pharmaceutical  Chemistry.  A 
Text-Book  for  Medical,  Dental,  and  Pharmaceutical  Students.  With 
Illustrations,  Glossary,  and  Complete  Index.  4th  Edition,  carefully 
Revised.  Cloth,  $2.75  ;  Sheep,  $3.25 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experi- 
ments. 8th  Ed.,  Revised.     281  Engravings.    Clo.,$4.25;  Lea.,  $5.25 

CALDWELL.  Elements  of  Qualitative  and  Quantitative 
Chemical  Analysis.     3d  Edition,  Revised.  >i-5° 


MEDICAL   BOOKS 


CAMERON.  Oils  and  Varnishes.  With  Illustrations,  Formulae, 
Tables,  etc.  $2.25 

CAMERON.     Soap  and  Candles.     54  Illustrations.  $2.00 

CLOWES  AND  COLEMAN.  Elementary  Practical  Chem- 
istry and  Qualitative  Analysis.  Adapted  for  Use  in  the  Labora- 
tories of  Schools  and  Colleges.     Illustrated.    Just  Ready.  $1-25 

GARDNER.  The  Brewer,  Distiller,  and  Wine  Manufac- 
turer. A  Hand-Book  for  all  Interested  in  the  Manufacture  and 
Trade  of  Alcohol  and  Its  Compounds.     Illustrated.  $t-5° 

GARDNER.  Bleaching,  Dyeing,  and  Calico  Printing.  With 
Formulae.     Illustrated.  $I-S° 

GROVES  AND  THORP.  Chemical  Technology.  The  Appli- 
cation of  Chemistry  to  the  Arts  and  Manufactures.  8  Volumes, 
with  numerous  Illustrations. 

Vol.  I.  Fuel  and  Its  Applications.     607  Illustrations  and  4  Plates. 

Cloth,  $5.00;  Half  Morocco,  $6.50 
Vol.11.  Lighting.  Illustrated.  Cloth,  $4.00;  Half  Morocco,  $5.50 
Vol.  III.  Lighting — Continued.  In  Press. 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.     5th  Ed.     Illustrated  and  interleaved,  $1.00 

LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic 
and  Organic.    Including  Urine  Analysis.     4th  Edition,  Rewritten. 

.80;   Interleaved,  $1.25 

LEFFMANN.  Progressive  Exercises  in  Practical  Chemis- 
try.    Illustrated.     2d  Edition.  $1.00 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Arranged 
to  Suit  the  Needs  of  Analytical  Chemists,  Dairymen,  and  Milk  Inspec- 
tors.    2d  Edition.     Enlarged,  Illustrated.  $'-25 

LEFFMANN.     Water  Analysis.     Illustrated.    3d  Edition.    $1.25 

LEFFMANN.  Structural  Formulae  for  the  Use  of  Students. 
Including  180  Structural  and  Stereo-Chemical  Formulae.  i2mo. 
Interleaved.  $1.00 

MUTER.  Practical  and  Analytical  Chemistry.  4th  Edition. 
Revised  to  meet  the  requirements  of  American  Medical  Colleges  by 
Claude  C.  Hamilton,  m.d.     51  Illustrations.  $'-25 

OETTEL.  Practical  Exercises  in  Electro-Chemistry.  Illus- 
trated.   Just  Ready.  -75 

OETTEL.     Introduction   to    Electro-Chemical    Experiments. 

Illustrated.    Just  R  .75 

RICHTER.  Inorganic  Chemistry.  4th  American,  from  6th  Ger- 
man Edition.  Authorized  translation  by  Edgar  F.  Smith,  m.a., 
ph.d.     89  Illustrations  and  a  Colored  Plate.  $I15 

RICHTER.  Organic  Chemistry.  3d  American  Edition.  Trans, 
from  the  last  German  by   EoGAK  F.Smith.     Illustrated.     In  Press. 

SMITH.  Electro-Chemical  Analysis.  2d  Edition,  Revised.  28 
Illustrations.  $i-*5 

SMITH  AND  KELLER.  Experiments.  Arranged  for  Students 
in  General  Chemistry.     3d  Edition.     Illustrated.  .60 

STAMMER.  Chemical  Problems.  With  Explanations  and  An- 
swers. .50 


SUBJECT   CATALOGUE. 


SUTTON.  Volumetric  Analysis.  A  Systematic  Handbook  for 
the  Quantitative  Estimation  of  Chemical  Substances  by  Measure, 
Applied  to  Liquids,  Solids,  and  Gases.  7th  Edition,  Revised.  112 
Illustrations.  $4-5° 

SYMONDS.  Manual  of  Chemistry,  for  Medical  Students. 
2d  Edition.  #2.00 

WATTS.  Organic  Chemistry.  2d  Edition.  By  Wm.  A.  Tilden, 
d.sc.,f.r.s.  (Being  the  13th  Edition  of  Fowne's  Organic  Chemistry.) 
Illustrated.  $2  00 

WATTS.  Inorganic  Chemistry.  Physical  and  Inorganic.  (Being 
the  14th  Edition  of  Fowne's  Physical  and  Inorganic  Chemistry.) 
With  Colored  Plate  of  Spectra  and  other  Illustrations.  $2.00 

WOODY.  Essentials  of  Chemistry  and  Urinalysis.  4th 
Edition.     Illustrated.  /«  Press. 

***  Special  Catalogue  0/  Books  on  Chemistry  free  upon  application. 

CHILDREN. 

CAUTLIE.  Feeding  of  Infants  and  Young  Children  by  Nat- 
ural and  Artificial  Methods.     Just  Ready.  $2.00 

HALE.  On  the  Management  of  Children  in  Health  and  Dis- 
ease. -5° 

HATFIELD.  Compend  of  Diseases  of  Children.  With  a 
Colored  Plate.     2d  Edition.  .80  ;    Interleaved,  J1.25 

IRELAND.  Mental  Affections  of  Children.  Idiocy,  Imbe- 
cility, etc.  In  Press. 

MEIGS.  Infant  Feeding  and  Milk  Analysis.  The  Examination 
of  Human  and  Cow's  Milk,  Cream,  Condensed  Milk,  etc.,  and 
Directions  as  to  the  Diet  of  Young  Infants.  -5° 

MONEY.  Treatment  of  Diseases  in  Children.  Including  the 
Outlines  of  Diagnosis  and  the  Chief  Pathological  Differences  Between 
Children  and  Adults.     2d  Edition.  $2.50 

POWER.  Surgical  Diseases  of  Children  and  their  Treat- 
ment by  Modern  Methods.     Illustrated.  $2.50 

STARR.  The  Digestive  Organs  in  Childhood.  The  Diseases  of 
the  Digestive  Organs  in  Infancy  and  Childhood.  With  Chapters  on 
the  Investigation  of  Disease  and  the  Management  of  Children.  2d 
Edition,  Enlarged.  Illustrated  by  two  Colored  Plates  and  numerous 
Wood  Engravings.  $2.00 

STARR.  Hygiene  of  the  Nursery.  Including  the  General  Regi- 
men and  Feeding  of  Infants  and  Children,  and  the  Domestic  Manage- 
ment of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.    Just  Ready.  $1.00 

TAYLOR  AND  WELLS.  The  Diseases  of  Children.  Illus- 
trated.    A  New  Text-Book.  Nearly  Ready. 

CLINICAL  CHARTS. 

GRIFFITH.  Graphic  Clinical  Chart  for  Recording  Temper- 
ature,^Respiration,  Pulse,  Day  of  Disease,  Date,  Age,  Sex, 
Occupation,  Name,  etc.  Printed  in  three  colors.  Sample  copies 
free.  Put  up  in  loose  packages  of  fifty,  .50.  Price  to  Hospitals,  500 
copies,  $4.00 ;  1000  copies,  $7.50.  With  name  of  Hospital  printed 
on,  .50  extra. 

KEEN'S  CLINICAL  CHARTS.  Seven  Outline  Drawings  of  the 
Body,  on  which  may  be  marked  the  Course  of  Disease,  Fractures, 
Operations,  etc.  Pads  of  fifty,  Ji.co.  Each  Drawing  may  also  be 
had  separately,  twenty-five  to  pad,  25  cents. 


MEDICAL   BOOKS. 


DEFORMITIES. 

REEVES.  Bodily  Deformities  and  Their  Treatment.  A 
Hand-Book  of  Practical  Orthopedics.     228  Illustrations.  $'-75 

HEATH  Injuries  and  Diseases  of  the  Jaws.  187  Illustrations. 
4th  Edition.  Cloth,  $4.50 

DENTISTRY. 

Special  Catalogue  0/  Dental  Books  sent  free  upon  application. 

BARRETT.  Dental  Surgery  for  General  Practitioners  and 
Students  of  Medicine  and  Dentistry.  Extraction  of  Teeth, 
etc.     3d  Edition.     Illustrated.  Nearly  Ready. 

BLODGETT.  Dental  Pathology.  By  Albert  N.  Blodghtt, 
m  D.,  late  Professor  of  Pathology  and  Therapeutics,  Boston  Dental 
College.     33  Illustrations.  $T-25 

FLAGG.  Plastics  and  Plastic  Filling,  as  Pertaining  to  the  Filling 
of  Cavities  in  Teeth  of  all  Grades  of  Structure.     4th  Edition.       $4-°o 

FILLEBROWN.  A  Text-Book  of  Operative  Dentistry. 
Written  by  invitation  of  the  National  Association  of  Dental  Facul- 
ties.    Illustrated.  $2.25 

GORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     6th  Edition,  Revised.  Cloth,  $4.00;  Sheep,  $5.00 

HARRIS.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery, 
and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S.  Gorgas,  m.d., 
d.d.s.     1250   Illustrations.  Cloth,  $6.00;  Leather,  $7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art  and 
Practice  of  Dentistry.  5th  Edition.  Revised  and  Enlarged  by  Fer- 
dinand F.  S.  Gorgas,  m.d.,  d.d.s.  Cloth,  $4.50;  Leather,  $$. 50 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Edition  187 
Illustrations.  $4-5° 

HEATH.  Lectures  on  Certain  Diseases  of  the  Jaws.  64 
Illustrations.  Boards,  .50 

RICHARDSON.  Mechanical  Dentistry.  7th  Edition.  Thor- 
oughly Revised  and  Enlarged  by  Dr.  Geo.  W.  Warren.  691  Illus- 
trations. Cloth,  $5.00;   Leather,  $6. 00 

SEWELL.  Dental  Surgery.  Including  Special  Anatomy  and 
Surgery.     3d  Edition,  with  200  Illustrations.  $2.00 

TAFT.  Operative  Dentistry.  A  Practical  Treatise.  5th  Edition. 
100  Illustrations.  In  Press. 

TAFT.     Index  of  Dental  Periodical  Literature.  $2.00 

TALBOT.  Irregularities  of  the  Teeth  and  Their  Treatment. 
2d  Edition      234  Illustrations.  $300 

TOMES.  Dental  Anatomy.  Human  and  Comparative.  235  Illus- 
trations.    4th  Edition.  $3-5° 

TOMES.     Dental  Surgery.  3d  Edition.     292  Illustrations.        J4.00 

WARREN.     Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    With  a  Chapter  on  Emergencies.     3d  Edition.     Illustrated. 
Just  Ready.  -8o;  Interleaved,  $1:25 

WARREN.  Dental  Prosthesis  and  Metallurgy.  129  Ills.  $1.25 

WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 

*»*  Special  Catalogue  of  Dental  Books  free  upon  application. 


SUBJECT   CATALOGUE. 


DICTIONARIES. 

GOULD.  The  Illustrated  Dictionary  of  Medicine,  Biology, 
and  Allied  Sciences.  Being  an  Exhaustive  Lexicon  of  Medicine 
and  those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry.  Dentistry,  Parmacology,  Microscopy,  etc.,  with  many 
useful  Tables  and  numerous  fine  Illustrations.  1633  pages.  3d  Ed. 
Sheep  or  Half  Dark  Green  Leather,  $10.00;   Thumb  Index,  #11.00 

Half  Russia,  Thumb  Index,  #12.00 

GOULD.  The  Medical  Student's  Dictionary.  Including  all  the 
Words  and  Phrases  Generally  Used  in  Medicine,  with  their  Proper 
Pronunciation  and  Definition,  Based  on  Recent  Medical  Literature. 
With  Tables  of  the  Bacilli,  Micrococci,  Mineral  Springs,  etc.,  of  the 
Arteries,  Muscles,  Nerves,  Ganglia,  and  Plexuses,  etc.  10th  Edition. 
Rewritten  and  Enlarged.  Completely  reset  from  new  type.  700  pp. 
Half  Dark  Leather,  $3.25;  Half  Morocco,  Thumb  Index,  #4.00 

GOULD.  The  Pocket  Pronouncing  Medical  Lexicon.  (12,000 
Medical  Words  Pronounced  and  Defined.)  Containing  all  the  Words, 
their  Definition  and  Pronunciation,  that  the  Medical,  Dental,  or 
Pharmaceutical  Student  Generally  Comes  in  Contact  With ;  also 
Elaborate  Tables  of  the  Arteries,  Muscles,  Nerves,  Bacilli,  etc.,  etc., 
a  Dose  List  in  both  English  and  Metric  System,  etc.,  Arranged  in  a 
Most  Convenient  Form  for  Reference  and  Memorizing. 

Full  Limp  Leather,  Gilt  Edges,  $1.00  ;  Thumb  Index,  $1.25 
70,000  Copies  of  Gould's  Dictionaries  Have  Been  Sold. 
***  Sample  Pages   and    Illustrations  and    Descriptive   Circulars    of 

Gould's  Dictionaries  sent  free  upon  application. 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art 
and  Practice  of  Dentistry.  5th  Edition.  Revised  and  Enlarged  by 
Ferdinand  J.  S.  Gorc;as,  m.d.,  d.d.s.    Cloth,  $4.50;   Leather,  $5.50 

LONGLEY.  Pocket  Medical  Dictionary.  With  an  Appendix, 
containing  Poisons  and  their  Antidotes,  Abbreviations  used  in  Pre- 
scriptions, etc.  Cloth,  .75;  Tucks  and  Pocket,  J1.00 

MAXWELL.  Terminologia  Medica  Polyglotta.  By  Dr. 
Theodore  Maxwell,  Assisted  by  Others.  $3-oo 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality 

in   reading   medical  literature   written   in  a  language  not   their  own. 

Each  term  is  usually  given  in  seven  languages,  viz.  :  English,  French, 

German,  Italian,  Spanish,  Russian,  and  Latin. 

TREVES  AND  LANG.    German-English  Medical  Dictionary. 

Half  Russia,  $3.25 

EAR  (see  also  Throat  and  Nose). 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharynx.  Includ- 
ing Anatomy  and  Physiology  of  the  Organ,  together  with  the  Treat- 
ment of  the  Affections  of  the  Nose  and  Pharynx  which  Conduce  to 
Aural  Disease.     122  Illustrations.  $5-°° 

BURNETT.     Hearing  and  How  to  Keep  It.     Illustrated.  .40 

DALBY.  Diseases  and  Injuries  of  the  Ear.  4th  Edition.  38 
Wood  Engravings  and  8  Colored  Plates.  #2.50 

PRITCHARD.  Diseases  of  the  Ear.  3d  Edition,  Enlarged. 
Many  Illustrations  and  Formulae.  $*-5° 

WOAKES.  Deafness,  Giddiness,  and  Noises  in  the  Head. 
4th  Edition.     Illustrated.  l2-°° 


MEDICAL   BOOKS. 


ELECTRICITY. 

BIGELOW.  Plain  Talks  on  Medical  Electricity  and  Bat- 
teries. With  a  Therapeutic  Index  and  a  Glossary.  43  Illustra- 
tions.    2d  Edition.  $1.00 

JONES.    Medical  Electricity.  2d  Edition.    112  Illustrations.    $2.50 

MASON.  Electricity  ;  Its  Medical  and  Surgical  Uses.  Numer- 
ous Illustrations.  .75 

EYE. 

A  Special  Circular  0/  Books  on  the  Eye  sent  Jree  upon  application. 

ARLT.  Diseases  of  the  Eye.  Clinical  Studies  on  Diseases  of  the 
Eye.     Authorized  Translation  by  Lyman  Warb,  m.d.     Illustrated. 

$1.25 

FICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  Trans- 
lated by  A.  B.  Hale,  m.  d.  157  Illustrations,  many  of  which  are  in 
colors,  and  a  glossary.  Cloth,  $4.50  ;  Sheep,  $5.50 

GOULD  AND  PYLE.  Compend  of  Diseases  of  the  Eye  and 
Refraction.  Including  Treatment  and  Operations,  and  a  Section 
on  Local  Therapeutics.  With  Formulae,  Useful  Tables,  a  Glossary, 
and  111  Illustrations,  several  of  which  are  in  colors.    Just  Ready. 

Cloth,  .80;   Interleaved,  £1.00 

GOWERS.  Medical  Ophthalmoscopy.  A  Manual  and  Atlas 
with  Colored  Autotype  and  Lithographic  Plates  and  Wood-cuts, 
Comprising  Original  Illustrations  of  the  Changes  of  the  Eye  in  Dis- 
eases of  the  Brain,  Kidney,  etc.     3d  Edition.  $4.00 

HARLAN.     Eyesight,  and  How  to  Care  for  It.     Illus.  .40 

HARTRIDGE.      Refraction.      96   Illustrations   and   Test   Types. 

8th  Edition,  Enlarged.  $1-50 

HARTRIDGE.      On  the  Ophthalmoscope.      3d  Edition.     With 

72  Colored  Plates  and  many  Wood-cuts.  $'-5° 

HANSELL   AND  BELL.      Clinical  Ophthalmology.     Colored 

Plate  of  Normal  Fundus  and  120  Illustrations.  J1.50 

MACNAMARA.  On  the  Eye.  5th  Edition.  Numerous  Colored 
Plates,  Diagrams  of  Eye,  Wood-cuts,  and  Test  Types.  $3-5° 

MORTON.  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Cor- 
rection of  its  Errors.  With  Chapter  on  Keratoscopy  and  Test 
Types.     6th  Edition.  $1.00 

OHLEMANN.  Ocular  Therapeutics.  Authorized  Translation, 
and  Edited  by  Dr.  Charles  A.  Oliver.  In  Press. 

PHILLIPS.  Spectacles  and  Eyeglasses.  Their  Prescription 
and  Adjustment.     2d  Edition.     49  Illustrations.  $1.00 

SWANZY.  Diseases  of  the  Eye  and  Their  Treatment.  6th 
Edition,  Revised  and  Enlarged.  158  Illustrations,  1  Plain  Plate, 
and  a  Zephyr  Test  Card.  $3.00 

THORINGTON.     Retinoscopy.    2d  Ed.  Illus.   Just  Ready.    $1.00 

WALKER.  Students'  Aid  in  Ophthalmology.  Colored  Plate 
and  40  other  Illustrations  and  Glossary.  |i-50 

FEVERS. 

COLLIE.  On  Fevers.  Their  History,  Etiology,  Diagnosis,  Prog- 
nosis, and  Treatment.     Colored  Plates.  $2.00 

GOODALL  AND  WASHBOURN.  Fevers  and  Their  Treat- 
ment.     Illustrated.  $3-oo 


10  SUBJECT  CATALOGUE. 

GOUT  AND  RHEUMATISM. 

DUCKWORTH.  A  Treatise  on  Gout.  With  Chromolithographs 
and  Engravings.  Cloth,  $6.00 

GARROD.  On  Rheumatism.  A  Treatise  on  Rheumatism  and 
Rheumatic  Arthritis.  Cloth,  $5.00 

HAIG.  Causation  of  Disease  by  Uric  Acid.  A  Contribution  to 
the  Pathology  of  High  Arterial  Tension,  Headache,  Epilepsy,  Gout, 
Rheumatism,  Diabetes,  Bright's  Disease,  etc.     4th  Edition.       $3.00 


HEADACHES. 

DAY.     On   Headaches.     The  Nature,  Causes,  and   Treatment  ot 

Headaches.     4th  Edition.     Illustrated.  $1.00 

HEALTH    AND     DOMESTIC    MEDI- 
CINE (see  also  Hygiene  and  Nursing). 

BUCKLEY.     The  Skin  in  Health  and  Disease.     Illus.  ,40 

BURNETT.     Hearing  and  How  to  Keep  It.     Illustrated.  .40 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

DULLES.     Emergencies.     4th  Edition.     Illustrated.  $1.00 
HARLAN.     Eyesight  and  How  to  Care  for  It.     Illustrated.     .40 

HARTSHORNE.     Our  Homes.     Illustrated.  .40 

OSGOOD.     The  'Winter  and  its  Dangers.  .40 

PACKARD.     Sea  Air  and  Bathing.  .40 

PARKES.     The  Elements  of  Health.  $1.25 

RICHARDSON.     Long  Life  and  How  to  Reach  It.  .40 

WESTLAND.     The  Wife  and  Mother.  $1.50 

WHITE.    The  Mouth  and  Teeth.     Illustrated.  .40 

■WILSON.     The  Summer  and  its  Diseases.  .40 

WOOD.     Brain  Work  and  Overwork.  .40 

STARR.     Hygiene  of  the  Nursery.     5th  Edition.  $1.00 

CANFIELD.     Hygiene  of  the  Sick-Room.  $1.25 


HEART. 

SANSOM.  Diseases  of  the  Heart.  The  Diagnosis  and  Pathology 
of  Diseases  of  the  Heart  and  Thoracic  Aorta.  With  Plates  and  other 
Illustrations.  $6.00 

HISTOLOGY. 

STIRLING.  Outlines  of  Practical  Histology.  368  Illustrations. 
2d  Edition,  Revised  and  Enlarged.     With  new  Illustrations.       |2.oo 

STOHR.  Histology  and  Microscopical  Anatomy.  Translated 
and  Edited  by  A.  Schaper,  m.d.,  Harvard  Medical  School.  268 
Illustrations.  fo.oo 


MEDICAL  BOOKS  U 


HYGIENE  AND  WATER  ANALYSIS. 

Special  Catalogue  of  Books  on  Hygiene  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Antisepsis,  Dis- 
infection, Bacteriology,  Immunity,  Heating  and  Ventilation,  and 
Kindred  Subjects.  $'-25 

COPLIN  AND  BEVAN.  Practical  Hygiene.  A  Complete 
American  Text-Book.     138  Illustrations.     Cloth,  $3.25  ;  Sheep,  $4. 25 

FOX.  Water,  Air,  and  Food.  Sanitary  Examinations  of  Water, 
Air,  and  Food.     100  Engravings.     2d  Edition,  Revised.  $3-5° 

KENWOOD.  Public  Health  Laboratory  Work.  116  Illustra- 
tions and  3  Plates.  $2.00 

LEFFMANN.  Examination  of  Water  for  Sanitary  and 
Technical  Purposes.     3d  Edition.    Illustrated.  ^1.25 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Illus- 
trated. $125 

LINCOLN.     School  and  Industrial  Hygiene.  .40 

MACDONALD.  Microscopical  Examinations  of  Water  and 
Air.     25  Lithographic  Plates,  Reference  Tables,  etc.    2d  Ed.      $2.50 

McNEILL.  The  Prevention  of  Epidemics  and  the  Construc- 
tion and  Management  of  Isolation  Hospitals.  Numerous  Plans 
and  Illustrations.  $3-5° 

NOTTER  AND  FIRTH.  The  Theory  and  Practice  of  Hygiene. 
(Being  the  9th  Edition  of  Parkes'  Practical  Hygiene,  rewritten  and 
brought  up  to  date.)  10  Plates  and  135  other  Illustrations.  1034 
pages.     8vo.  $7.00 

PARKES.  Hygiene  and  Public  Health.  By  Louis  C.  Parkes, 
m.d.     5th  Edition.     Enlarged.     Illustrated.  $2.50 

PARKES.  Popular  Hygiene.  The  Elements  of  Health.  A  Book 
for  Lay  Readers.     Illustrated.  $'-25 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic 
Management  of  the  Ordinary  Emergencies  of  Early  Life,  Massage, 
etc.     6th  Edition.     25  Illustrations.  $1.00 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By 
Various   Authors.     In    Three    Octave    Volumes.     Illustrated. 

Vol.  I,  $6.00;  Vol.  II,  J6.00;   Vol.  Ill,  $5.00 
*V*  Each  Volume  sold  separately.   Special  Circular  upon  application. 

WILSON.  Hand-Book  of  Hygiene  and  Sanitary  Science. 
With  Illustrations.     8th  Edition.  Preparing. 

WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  Author- 
ized Translation  by  Henky    LePPMANN,  M.D. ,  PH.D.  $1-25 

%*  Special  Catalogue  0/  Books  on  Hygiene  free  upon  application. 

LUNGS  AND  PLEURA. 

HARRIS  AND  BEALE.  Treatment  of  Pulmonary  Consump, 
tion.  $2.50 

POWELL.  Diseases  of  the  Lungs  and  Pleurae,  including 
Consumption.     Colored  Plates  and  other  Illus.     4th  Ed.  $4.00 

TUSSEY.  High  Altitudes  in  the  Treatment  of  Consumption. 
Just  Ready.  *'-5° 


n  SUBJECT   CATALOGUE. 


MASSAGE. 

KLEEN.  Hand-Book  of  Massage.  Authorized  translation  by 
Mussey  Hartwell,  m.d.,  ph.d.  With  an  Introduction  by  Dr.  S. 
Weir  Mitchell.  Illustrated  by  a  series  of  Photographs  Made 
Especially  by  Dr.  Kleen  for  the  American  Edition.  $2-25 

MURRELL.  Massotherapeutics.  Massage  as  a  Mode  of  Treat- 
ment.    5th  Edition.  $1.25 

OSTROM.  Massage  and  the  Original  Swedish  Move- 
ments. Their  Application  to  Various  Diseases  of  the  Body.  A 
Manual  for  Students,  Nurses,  and  Physicians.  Third  Edition,  En- 
larged.    94  Wood  Engravings,  many  of  which  are  original.  $1.00 


MATERIA    MEDICA    AND     THERA- 
PEUTICS. 

ALLEN,  HARLAN,  HARTE,  VAN  HARLINGEN.  A 
Hand-Book  of  Local  Therapeutics,  Being  a  Practical  Description 
of  all  those  Agents  Used  in  the  Local  Treatment  of  Diseases  of  the 
Eye,  Ear,  Nose  and  Throat,  Mouth,  Skin,  Vagina,  Rectum,  etc., 
such  as  Ointments,  Plasters,  Powders,  Lotions,  Inhalations,  Supposi- 
tories, Bougies,  Tampons,  and  the  Proper  Methods  of  Preparing  and 
Applying  Them.  Cloth,  $3.00  ;  Sheep,  $4.00 

BIDDLE.  Materia  Medica  and  Therapeutics.  Including  Dose 
List,  Dietary  for  the  Sick,  Table  of  Parasites,  and  Memoranda  of 
New  Remedies.  13th  Edition,  Thoroughly  Revised  in  accord- 
ance with  the  new  U.  S.  P.     64  Illustrations  and  a  Clinical   Index. 

Cloth,  #4. 00;  Sheep,  #5.00 

BRACKEN.  Outlines  of  Materia  Medica  and  Pharmacology.  By 
H.  M.  Bracken,  University  of  Minnesota.  Jz-75 

DAVIS.     Materia  Medica  and  Prescription  Writing.        $1 .50 

FIELD.     Evacuant  Medication.     Cathartics  and  Emetics.      $1.75 

GORQAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     6th  Edition,  Revised.    Just  Ready.  $400 

HELLER.  Essentials  of  Materia  Medica,  Pharmacy,  and 
Prescription  Writing.  #1.00 

MAYS.     Theine  in  the  Treatment  of  Neuralgia.     %  bound,  .50 

NAPHEYS.  Modern  Therapeutics,  gth  Revised  Edition,  En- 
larged and  Improved.  In  two  handsome  volumes.  Edited  by  Allen 
J.  Smith,  m.d.,  and  J.  Aubrey  Davis,  m.d. 

Vol.1.  General  Medicine  and  Diseases  of  Children.  $4.00 

Vol.  II.  General  Surgery,  Obstetrics,  and  Diseases  of  Women.   $4.00 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics,  including  the  Action  of  Medicines,  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and  For- 
mulae. 6th  Edition,  Revised  and  Enlarged.  With  Thumb  Index  in 
each  copy.  Cloth,  #4. 50;  Sheep,  #5. 50 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  Writing,  with  Special  Reference  to  the  Physiologi- 
cal Action  of  Drugs.  6th  Revised  and  Improved  Edition ,  based  upon 
the  U.  S.  P.  1890  .80;  Interleaved,  $1.25 


MEDICAL  BOOKS.  13 


SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepara- 
tions. With  chapters  on  Synthetic  Organic  Remedies,  Insects  In- 
jurious to  Drugs,  and  Pharmacal  Botany.  A  Glossary  and  543  Illus- 
trations, many  of  which  are  original.  $400 

WARING.  Practical  Therapeutics.  4th  Edition,  Revised  and 
Rearranged.  Cloth,  $2.00;   Leather,  $3.00 

WHITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Phar- 
macology, and  Therapeutics.  3d  American  Edition,  Revised  by 
Reynold  W.  Wilcox,  m.a.,  m.d.,  ll.d.      Clo.,  $2.75;  Lea.,  $3.25 


MEDICAL    JURISPRUDENCE     AND 
TOXICOLOGY. 

REESE.  Medical  Jurisprudence  and  Toxicology.  A  Text-Book 
for  Medical  and  Legal  Practitioners  and  Students.  4th  Edition. 
Revised  by  Henry  Leffmann,  m.d.       Clo.,  $3.00;  Leather,  $3.50 

"  To  the  student  of  medical  jurisprudence  and  toxicology  it  is  in- 
valuable, as  it  is  concise,  clear,  and  thorough  in  every  respect." — The 
A  merican  Journal  o/the  Medical  Sciences. 

MANN.     Forensic  Medicine  and  Toxicology.     Illus.  $6.50 

MURRELL.  What  to  Do  in  Cases  of  Poisoning.  7th 
Edition,  Enlarged.  $1.00 

TANNER.  Memoranda  of  Poisons.  Their  Antidotes  and  Tests. 
7th  Edition.  .75 

MICROSCOPY. 

BEALE.  The  Use  of  the  Microscope  in  Practical  Medicine. 
For  Students  and  Practitioners.with  Full  Directions  for  Examining  the 
Various  Secretions,  etc.,  by  the  Microscope.  4th  Ed.   500  lllus.   J6.50 

BEALE.  How  to  Work  with  the  Microscope.  A  Complete 
Manual  of  Microscopical  Manipulation,  containing  a  Full  Description 
of  many  New  Processes  of  Investigation,  with  Directions  for  Examin- 
ing Objects  Under  the  Highest  Powers,  and  for  Taking  Photographs 
of  Microscopic  Objects.  5th  Edition.  400  Illustrations,  many  of 
them  colored.  $6-5° 

CARPENTER.  The  Microscope  and  Its  Revelations.  7th 
Edition.     800  Illustrations  and  many  Lithographs.  $550 

LEE.  The  Microtomist's  Vade  Mecum.  A  Hand-Book  of 
Methods  of  Microscopical  Anatomy.  887  Articles.  4th  Edition, 
Enlarged.    Just  Ready.  $4.00 

MACDONALD.  Microscopical  Examinations  of  Water  and  Air. 
25  Lithographic  Plates,  Reference  Tables,  etc.     2d  Edition.        £2.50 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bacteri- 
ology, Neoplasms,  Urinary  Examination,  etc.  Numerous  Illus- 
trations, some  of  which  are  printed  in  colors.  $2-5° 

WETHERED.  Medical  Microscopy.  A  Guide  to  the  Use  of  the 
Microscope  in  Practical  Medicine.     100  Illustrations.  $2.00 


14  SUBJECT  CATALOGUE. 


MISCELLANEOUS. 

BLACK.  Micro-Organisms.  The  Formation  of  Poisons.  A 
Biological  Study  of  the  Germ  Theory  of  Disease.  .75 

BURNETT.  Foods  and  Dietaries.  A  Manual  of  Clinical  Diet- 
etics.    2d  Edition.  $1.50 

GOULD.  Borderland  Studies.  Miscellaneous  Addresses  and 
Essays.     i2mo.  #2.00 

GOWERS.    The  Dynamics  of  Life.  .75 

HAIG.  Causation  of  Disease  by  Uric  Acid.  A  Contribution  to 
the  Pathology  of  High  Arterial  Tension,  Headache,  Epilepsy,  Gout, 
Rheumatism,  Diabetes,  Bright's  Disease,  etc.     3d  Edition-.         $3.00 

HARE.     Mediastinal  Disease.     Illustrated  by  six  Plates.        $2.00 

HEMMETER.  Diseases  of  the  Stomach.  Their  Special  Path- 
ology, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy,  Diet- 
etics, Surgery,  etc.    Illustrated.    Just  Ready.     Clo.  $6.00  ;  Sh.  $7.00 

HENRY.     A  Practical  Treatise  on  Anemia.  Half  Cloth,  .50 

LEFFMANN.  The  Coal-Tar  Colors.  With  Special  Reference  to 
their  Injurious  Qualities  and  the  Restrictions  of  their  Use.  A  Trans- 
lation of  Theodore  Weyl's  Monograph.  $1.25 

MARSHALL.  History  of  Woman's  Medical  College  of  Penn- 
sylvania.   Just  Ready.  #i-5° 

NEW  SYDENHAM  SOCIETY'S  PUBLICATIONS.  Circulars 
upon  application.  Per  Annum,  $8 .00 

TREVES.    Physical  Education  :  Its  Effects,  Methods,  Etc.  .75 
LIZARS.     The  Use  and  Abuse  of  Tobacco.  .40 

PARRISH.  Alcoholic  Inebriety  from  a  Medical  Standpoint, 
with  Cases.  $1.00 

ST.  CLAIR.     Medical  Latin.  $1.00 

NERVOUS  DISEASES. 

BEEVOR.  Diseases  of  the  Nervous  System  and  their  Treat- 
ment. In  Press. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Cen- 
tral Nervous  System.     With  many  original  Illustrations. 

Preparing. 

GOWERS.  Manual  of  Diseases  of  the  Nervous  System.  A 
Complete  Text-Book.  2d  Edition,  Revised,  Enlarged,  and  in  many 
parts  Rewritten.  With  many  new  Illustrations.  Two  volumes. 
Vol.  I.  Diseases  of  the  Nerves  and  Spinal  Cord.  Clo.  $3.00  ;  Sh.  $4.00 
Vol.  II.  Diseases  of  the  Brain  and  Cranial  Nerves;  General  and 
Functional  Disease.  Cloth,  £4.00;  Sheep,  $5.00 

GOWERS.    Syphilis  and  the  Nervous  System.  $1.00 

GOWERS.  Diagnosis  of  Diseases  of  the  Brain.  2d  Edition. 
Illustrated.  $i-5° 

GOWERS.  Clinical  Lectures.  A  New  Volume  of  Essays  on  the 
Diagnosis,  Treatment,  etc.,  of  Diseases  of  the  Nervous  System.  J2.00 

GOWERS.  Epilepsy  and  Other  Chronic  Convulsive  Diseases. 
2d  Edition.  In  Press 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and 
Functions  of.     Numerous  Illustrations.  $2-5° 

OBERSTEINER.  The  Anatomy  of  the  Central  Nervous  Or- 
gans. A  Guide  to  the  Study  of  their  Structure  in  Health  and  Dis- 
ease.    198  Illustrations.  $5-5° 


MEDICAL  BOOKS.  15 


ORMEROD.  Diseases  of  the  Nervous  System.  66  Wood  En- 
gravings. ^I.OO 

OSLER.     Cerebral  Palsies  of  Children.     A  Clinical  Study.    $2.00 

OSLER.     Chorea  and  Choreiform  Affections.  $2.00 

PRESTON.  Hysteria  and  Certain  Allied  Conditions.  Their 
Nature  and  Treatment.     Illustrated.    Just  Ready.  $2.00 

WATSON.     Concussions.  An  Experimental  Study  of  Lesions  Aris- 
ing from  Severe  Concussions.  Paper  cover,  Ji.oo 
WOOD.     Brain  Work  and  Overwork.  .40 

NURSING. 

Special  Catalogue  0/  Books  for  Nurses  sent  free  upon  application. 
BROWN.     Elementary  Physiology  for  Nurses.  .75 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses  and 
Others.  Being  a  Brief  Consideration  of  Asepsis,  Antisepsis,  Disinfec- 
tion, Bacteriology,  Immunity,  Heating  and  Ventilation,  and  Kindred 
Subjects  for  the  Use  of  Nurses  and  Other  Intelligent  Women.     $1.25 

CULLINGWORTH.  A  Manual  of  Nursing,  Medical  and  Sur- 
gical.    3d  Edition  with  Illustrations.  .75 

CULLINGWORTH.  A  Manual  for  Monthly  Nurses.  3d  Ed.  .40 
CUFF.     Lectures  to  Nurses  on  Medicine.   25  Illustrations.  $1.00 
DOMVILLE.     Manual  for  Nurses  and  Others  Engaged  in  At- 
tending the  Sick.    8th  Edition.   With  Recipes  for  Sick-room  Cook- 
ery, etc.  .75 

FULLERTON.     Obstetric  Nursing.     40  Ills.     4th  Ed.  $1.00 

FULLERTON.  Nursing  in  Abdominal  Surgery  and  Diseases 
of  Women.  Comprising  the  Regular  Course  of  Instruction  at  the 
Training-School  of  the  Women's  Hospital,  Philadelphia.  2d  Edition. 
70  Illustrations.  $1.50 

HUMPHREY.  A  Manual  for  Nurses.  Including  General 
Anatomy  and  Physiology,  Management  of  the  Sick-Room,  etc.  15th 
Edition.     Illustrated.  $1.00 

SH  AWE.  Notes  for  Visiting  Nurses,  and  all  those  Interested 
in  the  Working  and  Organization  of  District,  Visiting,  or 
Parochial  Nurse  Societies.  With  an  Appendix  Explaining  the 
Organization  and  Working  of  Various  Visiting  and  District  Nurse  So- 
cieties, by  Hblen  C.  Jenks,  of  Philadelphia.  $1.00 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic  Man- 
agement of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.     Just  Ready.  $1.00 

TEMPERATURE  AND  CLINICAL  CHARTS.     See  page  6. 

VOSWINKEL.     Surgical  Nursing,     m  Illustrations.  $1.00 

*»*  Special  Catalogue  of  Books  on  Nursing  fret  upon  application. 


OBSTETRICS. 

BAR.  Antiseptic  Midwifery.  The  Principles  of  Antiseptic  Meth- 
ods Applied  to  Obstetric  Practice.  Authorized  Translation  by 
Henky  I).  FrT,  m.d..  with  an  Appendix  by  the  Author.  $1.00 


16  SUBJECT   CATALOGUE. 

CAZEAUX  AND  TARNIER.  Midwifery.  With  Appendix  by 
Mundb.  The  Theory  and  Practice  of  Obstetrics,  including  the  Dis- 
eases of  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc. 
8th  Edition.  Illustrated  by  Chromo-Lithographs,  Lithographs,  and 
other  full-page  Plates,  seven  of  which  are  beautifully  colored,  and 
numerous  Wood  Engravings.  Cloth,  $4.50  ;  Full  Leather,  #5.50 

DAVIS.  A  Manual  of  Obstetrics.  Being  a  Complete  Manual  for 
Physicians  and  Students.  2d  Edition.  16  Colored  and  other  Plates 
and  134  other  Illustrations.  #2.00 

JELLETT.     The  Practice  of  Midwifery.     Illustrated.  $1.75 

LANDIS.  Compend  of  Obstetrics.  5th  Edition,  Revised  by  Wm. 
H.  Wells,  Assistant  Demonstrator  of  Clinical  Obstetrics,  Jefferson 
Medical  College.     With  many  Illustrations,  .80  ;  Interleaved,  $1.25. 

SCHULTZE.  Obstetrical  Diagrams.  Being  a  series  of  20  Col- 
ored Lithograph  Charts,  Imperial  Map  Size,  of  Pregnancy  and  Mid- 
wifery, with  accompanying  explanatory  (German)  text  illustrated 
by  Wood  Cuts.     2d  Revised  Edition. 

Price  in  Sheets,  $26.00  ;  Mounted  on  Rollers,  Muslin  Backs,  $36.00 

STRAHAN.  Extra-Uterine  Pregnancy.  The  Diagnosis  and 
Treatment  of  Extra-Uterine  Pregnancy.  .75 

WINCKEL.     Text-Book  of  Obstetrics,  Including  the  Pathol-, 
ogy  and  Therapeutics   of  the   Puerperal   State.     Authorized 
Translation  by  J.  Clifton  Edgar,  a.m.,  m.d.  With  nearly  200  Illus- 
trations. Cloth,  $5.00;  Leather,  $6.00 

FULLERTON.    Obstetric  Nursing.     4th  Ed.    Illustrated.    $1.00 

SHIBATA.    Obstetrical  Pocket-Phantom  with  Movable  Child 

and  Pelvis.     Letter  Press  and  Illustrations.  $1.00 

PATHOLOGY. 

BARLOW.     General  Pathology.  In  Press. 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies  Designed  for 
the  Use  of  Hospitals  for  the  Insane  and  other  Public  Institutions. 
Ten  full-page  Plates  and  other  Illustrations.  $125 

BLODGETT.  Dental  Pathology.  By  Albert  N.  Blodgett, 
m.d.,  late  Professor  of  Pathology  and  Therapeutics,  Boston  Dental 
College.     33  Illustrations.  $!-z5 

COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Technic 
of  Post-Mortems.  Mrthods  of  Pathologic  Research,  etc.  265  Illus- 
trations, many  of  which  are  original.     121110.    Just  Ready.         $3.00 

GILLIAM.     Pathology.  A  Hand-Book  for  Students.  47  Illus.     .75 

HALL.  Compend  of  General  Pathology  and  Morbid  Anatomy. 

91  very  fine  Illustrations.  .80;   Interleaved,  $1.25 

VIRCHOW.  Post-Mortem  Examinations.  A  Description  and 
Explanation  of  the  Method  of  Performing  Them  in  the  Dead  House 
of  the  Berlin  Charity  Hospital,  with  Special  Reference  to  Medico- 
Legal  Practice.     3d  Edition,  with  Additions.  .75 

WHITACRE.  Laboratory  Text-Book  of  Pathology.  With 
121  Illustrations.    Just  Ready.  $1.5° 

PHARMACY. 

Special  Catalogue  0/  Books  on  Pharmacy  sent  free  upon  application. 
COBLENTZ.      Manual   of  Pharmacy.      A   New  and   Complete 

Text-Book  by  the  Professor  in  the  New  York  College  of  Pharmacy. 

2d  Edition,  Revised  and  Enlarged.   437  Illus.   Cloth,  $3.50  ;  Sh.,  $4  50 


MEDICAL   BOOKS.  17 


BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  ot  the  Materia 
Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Established  Pre- 
parations, an  Index  of  Diseases  and  their  Remedies.     7th  Ed.     $2.00 

BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Proprietary 
Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and  Cosmetics, 
Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chemicals, 
Scientific  Processes,  and  an  Appendix  of  Useful  Tables.  10th  Edi- 
tion, Revised.  $2.00 

BEASLEY.  Pocket  Formulary.  A  Synopsis  of  the  British  and 
Foreign  Pharmacopoeias.  Comprising  Standard  and  Approved 
Formulae  for  the  Preparations  and  Compounds  Employed  in  Medical 
Practice,     nth  Edition.  J2.00 

PROCTOR.  Practical  Pharmacy.  Lectures  on  Practical  Phar- 
macy. With  Wood  Engravings  and  32  Lithographic  Fac-simile 
Prescriptions.  3d  Edition,  Revised,  and  with  Elaborate  Tables  of 
Chemical  Solubilities,  etc.  $3-oo 

ROBINSON.  Latin  Grammar  of  Pharmacy  and  Medicine. 
2d  Edition.     With  elaborate  Vocabularies.  $175 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepar- 
ations. With  Chapters  on  Synthetic  Organic  Remedies,  Insects 
Injurious  to  Drugs,  and  Pharmacal  Botany.  A  Glossary  and  543 
Illustrations,  many  of  which  are  original.     Cloth, $4. 00;  Sheep,  JJ5.00 

SCOVILLE.  The  Art  of  Compounding.  Second  Edition,  Re- 
vised and  Enlarged.    Just  Ready.  Cloth,  #2. 50  ;  Sheep,  #3.50 

STEWART.  Compend  of  Pharmacy.  Based  upon  "  Reming- 
ton's Text-Book  of  Pharmacy."  5th  Edition,  Revised  in  Accord- 
ance with  the  U.  S.  Pharmacopoeia,  1890.  Complete  Tables  of 
Metric  and  English  Weights  and  Measures.     .80;    Interleaved,  #1.25 

UNITED  STATES  PHARMACOPOEIA.  1890.  7th  Decennial 
Revision.  Cloth,  $2.50  (postpaid,  $2.77) ;  Sheep,  $3.00  (postpaid, 
$3.27) ;  Interleaved,  $4. 00  (postpaid,  $4.50);  Printed  on  one  side  ot 
page  only,  unbound,  $3.50  (postpaid,  5390). 

Select  Tables  from  the  U.  S.  P.  (1890).  Being  Nine  of  the  Most 
Important  and  Useful  Tables,  Printed  on  Separate  Sheets.  Care- 
fully put  up  in  patent  envelope.  .25 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.     600  Prescriptions  and  Formulas.    6th  Edition. 

Cloth,  $4  50;  Sheep,  $5.50 

***  Special  Catalogue  0/  Books  on  Pharmacy  free  upon  application. 


PHYSICAL  DIAGNOSIS. 

FENWICK.  Medical  Diagnosis.  8th  Edition.  Rewritten  and 
very  much  Enlarged.     135  Illustrations.  Cloth,  $2.50 

TYSON.  Hand-Book  of  Physical  Diagnosis.  For  Students  and 
Physicians.  By  the  Professor  of  Clinical  Medicine  in  the  University 
of  Pennsylvania.    Illus.    3d  Ed.,  Improved  and  Enlarged.  In  Press. 

MEMMINGER.     Diagnosis  by  the  Urine.     23  Illus.  $1.00 

2 


18  SUBJECT   CATALOGUE. 

PHYSIOLOGY. 

BRUBAKER.  Compend  of  Physiology.  8th  Edition,  Revised 
and  Enlarged.     Illustrated.  .80;  Interleaved,  $1. 25 

KIRKE.  Physiology.  (14th  Authorized  Edition.  Dark-Red  Cloth.) 
A  Hand-Book  of  Physiology.  14th  Edition,  Revised  and  Enlarged. 
By  Prof.  W.  D  Halliburton,  of  Kings  College,  London.  661 
Illustrations,   some  of    which  are  printed  in  colors. 

Cloth,  $3. 00;  Leather,  $3. 25 

LANDOIS.    A    Text-Book    of  Human    Physiology,  Including 

Histology  and  Microscopical  Anatomy,  with  Special   Reference  to 

the  Requirements  of  Practical  Medicine.     5th  American,  translated 

from  the  9th  German   Edition,  with  Additions   by  Wm.  Stirling, 

m.d.,d.sc.    845  lllus.,  many  of  which  are  printed  in  colors.    In  Press. 

STARLING.     Elements  of  Human  Physiology.     100  Ills.    $1.00 

STIRLING.      Outlines   of    Practical    Physiology.       Including 

Chemical  and  Experimental  Physiology,  with  Special  Reference  to 

Practical  Medicine.     3d  Edition.     289  Illustrations.  $2.00 

TYSON.     Cell  Doctrine.     Its  History  and  Present  State.        $1.50 

YEO.     Manual   of    Physiology.      A  Text-Book  for  Students    of 

Medicine.     By  Gerald  F.   Yeo,  m.d.,  f.r.c.s.     6th  Ecjition.     254 

Illustrations  and  a  Glossary.  Cloth,  #2.50  ;  Leather,  $3.00 

PRACTICE. 

BEALE.     On  Slight  Ailments;  their  Nature  and  Treatment. 

2d  Edition,  Enlarged  and  Illustrated.  J1.25 

CHARTERIS.      Practice  of  Medicine.    6th  Edition.  $2.00 

FOWLER.      Dictionary  of   Practical    Medicine.  "  By  various 

writers.  An  Encyclopaedia  of  Medicine.  Clo.,$3-oo;  Half  Mor.  $4.00 
HUGHES.    Compend  of  the  Practice  of  Medicine.    5th  Edition, 

Revised  and  Enlarged. 

Part  I.  Continued,  Eruptive,  and  Periodical  Fevers,  Diseases  of  the 
Stomach,  Intestines,  Peritoneum,  Biliary  Passages,  Liver,  Kid- 
neys, etc.,  and  General  Diseases,  etc. 

Part  II.  Diseases  of  the  Respiratory  System,  Circulatory  System, 
and  Nervous  System;  Diseases  of  the  Blood,  etc. 

Price  of  each  part,  .80;  Interleaved,  $1.25 

Physician's  Edition.  In  one  volume,  including  the  above  two 
parts,  a  Section  on  Skin  Diseases,  and  an  Index.  5th  Revised, 
Enlarged  Edition.     568  pp.  Full  Morocco,  Gilt  Edge,  $2.25 

ROBERTS.  The  Theory  and  Practice  of  Medicine.  The 
Sections  on  Treatment  are  especially  exhaustive.  9th  Edition, 
with  Illustrations.  Cloth,  $4.50;  Leather,  $5. 50 

TAYLOR.     Practice  of  Medicine.  Cloth,  $2.00;  Sheep,  $2. 50 

TYSON.  The  Practice  of  Medicine.  By  James  Tyson,  m.d., 
Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania. 
A  Complete  Systematic  Text-book  with  Special  Reference  to  Diag- 
nosis and  Treatment.     Illustrated.     8vo. 

Cloth,  $5.50;   Leather,  $6.50;  Half  Russia,  $7. 50 

PRESCRIPTION  BOOKS. 

BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  of  the  Materia, 
Medica,  Lists  of  the  Doses  of  all  Officinal  and  Established  Prepara- 
tions, and  an  Index  of  Diseases  and  their  Remedies.     7th  Ed.     $2.00 


MEDICAL   BOOKS.  19 


BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Proprie- 
tary Medicines,  Druggists'  Nostrums,  etc.  ;  Perfumery  and  Cos- 
metics, Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chem- 
icals, Scientific  Processes,  and  an  Appendix  of  Useful  Tables, 
ioth  Edition,  Revised.  $2.00 

BEASLEY.  Pocket  Formulary.  A  Synopsis  of  the  British  and 
Foreign  Pharmacopoeias.  Comprising  Standard  Formulae  for  the 
various  Preparations  and  Compounds,     nth  Edition.        Cloth,  $2. 00 

PEREIRA.  Prescription  Book.  Containing  Lists  of  Phrases 
and  Abbreviations  Used  in  Prescriptions,  Grammatical  Construction 
of  Prescriptions,  etc.     16th  Edition.  Cloth,  .75  ;  Tucks,  $1. 00 

WYTHE.     Dose  and  Symptom  Book.    Containing  the  Doses  and 

Uses  of  all  the  Principal  Articles  of  the  Materia  Medica.     17th  Ed. 

Cloth,  .75  ;  Leather,  with  Tucks  and  Pocket,  $1.00 

SKIN. 

BULKLEY.    The  Skin  in  Health  and  Disease.    Illustrated.    .40 
CROCKER.     Diseases  of  the  Skin.     Their   Description,  Pathol- 
ogy, Diagnosis,  and  Treatment,  with  Special  Reference  to  the  Skin 
Eruptions  of  Children.   92  lllus.   2d  Edition.   Cloth, $4. 50  ;  Sh.,  $5.50 
IMPEY.     Leprosy.     37  Plates.     8vo.  $3-50 

SCHAMBERG.  Diseases  of  the  Skin.  Illustrated.  Being  No. 
16  ?  Quiz-Compend  ?  Series.  Cloth,  .80;  Interleaved,  #1.25 

VAN  HARLINGEN.  On  Skin  Diseases.  A  Practical  Manual 
of  Diagnosis  and  Treatment,  with  special  reference  to  Differential 
Diagnosis.  3d  Edition,  Revised  and  Enlarged.  With  Formulae 
and  60  Illustrations,  some  of  which  are  printed  in  colors.        J275 

SURGERY  AND  SURGICAL  DIS- 
EASES. 

CAIRD  ANDCATHCART.  Surgical  Hand-Book.  5th  Edition, 
Revised.     188  Illustrations.  Full  Red  Morocco,  $2. 50 

DEAVER.  Appendicitis,  Its  Symptoms,  Diagnosis,  Pathol- 
ogy, Treatment,  and  Complications.  Elaborately  Illustrated 
with  Colored  Plates  and  other  Illustrations.  Cloth,  $3.50 

DEAVER.  Surgical  Anatomy.  With  200  Illustrations,  Drawn  by  a 
Special  Artist  from  Directions  made  for  the  Purpose.   In  Preparation. 

DULLES.  What  to  Do  First  in  Accidents  and  Poisoning. 
5th  Edition.     New  Illustrations.  $1.00 

HACKER.  Antiseptic  Treatment  of  Wounds,  According  to 
the  Method  in  Use  at  Professor  Billroth's  Clinic,  Vienna.  .50 

HAMILTON.  Lectures  on  Tumors,  from  a  Clinical  Stand- 
point.    Third  Edition,  Revised,  with  New  Illustrations.     In  Press. 

HEATH.  Minor  Surgery  and  Bandaging,  ioth  Ed.,  Revised 
and  Enlarged.     158  Illustrations,  62  Formulae,  Diet  List,  etc.      $1.25 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Edition. 
187  Illustrations.  £4  50 

HEATH.  Lectures  on  Certain  Diseases  of  the  Jaws.  64  Illus- 
trations. Boards,  .50 

HORW1TZ.  Compend  of  Surgery  and  Bandaging,  including 
Minor  Surgery,  Amputations,  Fractures,  Dislocations,  Surgical  Dis- 
eases, and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential  Diagno- 
sis and  Treatment.  5th  Edition,  very  much  Enlarged  and  Rear- 
ranged.   167  Illustrations,  98  Formulx.   Clo.,.8o;  Interleaved,  $  1.25 


20  SUBJECT  CATALOGUE. 


JACOBSON.     Operations    of   Surgery.     Over  200  Illustrations. 

Cloth,  #3.00;  Leather,  $4.00 

JACOBSON.    Diseases  of  the  Male  Organs  of  Generation. 

88   Illustrations.  $6.00 

MACREADY.    A  Treatise    on    Ruptures.     24   Full-page   Litho- 
graphed Plates  and  Numerous  Wood  Engravings.  Cloth,  $6.00 
MAYLARD,   Surgery  of  the  Alimentary  Canal.   134  lllus.  #7.50 

MOULLIN.  Text-Book  of  Surgery.  With  Special  Reference  to 
Treatment.  3d  American  Edition.  Revised  and  edited  by  John  B. 
Hamilton,  m.d.,  ll.d.,  Professor  of  the  Principles  of  Surgery  and 
Clinical  Surgery,  Rush  Medical  College,  Chicago.  623  Illustrations, 
over  200  of  which  are  original,  and  many  of  which  are  printed  in 
colors.  Handsome  Cloth,  $6.00;  Leather,  $7.00 

"  The  aim  to  make  this  valuable  treatise  practical  by  giving  special 

attention  to   questions  of  treatment  has  been  admirably  carried  out. 

Many  a  reader  will  consult  the  work  with  a  feeling  of  satisfaction  that 

his  wants  have  been  understood,  and  that  they  have  been  intelligently 

met." —  The  American  Journal  of  Medical  Science. 

ROBERTS.  Fractures  of  the  Radius.  A  Clinical  and  Patho- 
logical Study.     33  Illustrations.  .  $1.00 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  ot 
all  the  Principal  Operations.    224  lllus.  6th  Ed.    2  Vols.  Clo.,  #10.00 

SWAIN.     Surgical  Emergencies.     Fifth  Edition.         Cloth,  $1.75 

VOSWINKEL.     Surgical  Nursing,     in  Illustrations.  jji.oo 

WALSHAM.  Manual  of  Practical  Surgery.  5th  Ed.,  Re- 
vised and  Enlarged.     With  380  Engravings.    Clo.,  $2.00;   Lea.,  #2.50 

WATSON.  On  Amputations  of  the  Extremities  and  Their 
Complications.    250  Illustrations.  $5-5° 

THROAT   AND    NOSE   (see  also  Ear). 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

HALL.      Diseases    of   the    Nose    and    Throat.     Two    Colored 

Plates  and  59  Illustrations.  $2.50 

HUTCHINSON.     The  Nose  and  Throat.     Including  the   Nose, 

Naso-Pharynx,  Pharynx,  and   Larynx.     Illustrated  by   Lithograph 

Plates  and  40  other  Illustrations.     2d  Edition.  In  Press. 

MACKENZIE.  The  Pharmacopoeia  of  the  London  Hospital 
for  Diseases  of  the  Throat.  5th  Edition,  Revised  by  Dr.  F. 
G.  Harvey.  gi.oo 

McBRIDE.  Diseases  of  the  Throat,  Nose,  and  Ear.  A  Clinical 
Manual.    With  colored  lllus.  from  original  drawings.   2d  Ed.       #6.00 

POTTER.  Speech  and  its  Defects.  Considered  Physiologically, 
Pathologically,  and  Remedially.  $1.00 

WOAKES.  Post-Nasal  Catarrh  and  Diseases  of  the  Nose 
Causing  Deafness.     26  Illustrations.  $1.00 

URINE  AND  URINARY  ORGANS. 

ACTON.  The  Functions  and  Disorders  of  the  Reproductive 
Organs  in  Childhood,  Youth,  Adult  Age,  and  Advanced  Life, 
Considered  in  their  Physiological,  Social,  and  Moral  Relations. 
8th  Edition.  $i-75 

ALLEN.    Albuminous  and  Diabetic  Urine.    lllus.  $2.25 


MEDICAL   BOOKS.  21 

BROCKBANK.     Gall  Stones.  $2.25 

BEALE.     One    Hundred   Urinary   Deposits.     On  eight  sheets, 
for  the  Hospital,  Laboratory,  or  Surgery.  Paper,  $2.00 

HOLLAND.    The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.     Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.    Illustrated  and  Interleaved.    5th  Ed.  $1.00 
MEMMINGER.     Diagnosis  by  the  Urine.     23  Illus.  $1.00 

MOULLIN.     Enlargement  of  the  Prostate.     Its  Treatment  and 
Radical  Cure.     Illustrated.  $i-5° 

THOMPSON.     Diseases  of  the  Urinary  Organs.    8th  Ed.  $3.00 
TYSON.     Guide  to   Examination  of  the  Urine.     For  the  Use  of 
Physicians  and  Students.     With  Colored  Plate  and   Numerous  Illus- 
trations engraved  on  wood.     9th  Edition,  Revised.  $1.25 
VAN    NUYS.     Chemical  Analysis  of  Healthy   and   Diseased 
Urine,  Qualitative  and  Quantitative.    39  Illustrations.       $1.00 


VENEREAL  DISEASES. 

COOPER.  Syphilis.  2d  Edition,  Enlarged  and  Illustrated  with 
20  full-page  Plates.  $5-oo 

GOWERS.     Syphilis  and  the  Nervous  System.  1.00 

JACOBSON.     Diseases  of  the  Male  Organs  of  Generation.    88 

Illustrations.  $6.00 

VETERINARY. 

ARMATAGE.  The  Veterinarian's  Pocket  Remembrancer. 
Being  Concise  Directions  for  the  Treatment  of  Urgent  or  Rare  Cases, 
Embracing  Semeiology,  Diagnosis,  Prognosis,  Surgery,  Treatment, 
etc.     2d  Edition.  Boards,  $1. 00 

BALLOU.  Veterinary  Anatomy  and  Physiology.  29  Graphic 
Illustrations.  .80;   Interleaved,  $1. 25 

TUSON.  Veterinary  Pharmacopceia.  Including  the  Outlines  of 
Materia  Medica  and  Therapeutics.     5th  Edition.  $2.25 


WOMEN,  DISEASES  OF. 

BYFORD  (H.  T.).  Manual  of  Gynecology.  Second  Edition, 
Revised  and  Enlarged  by  100  pages.  With  341  Illustrations,  many 
of  which  are  from  original  drawings.    Just  Ready.  $3  00 

BYFORD  (W.  H.).  Diseases  of  Women.  4th  Edition.  306 
Illustrations.  Cloth,  $2.00 

DUHRSSEN.  A  Manual  of  Gynecological  Practice.  105 
Illustrations.  $lS° 

LEWERS.     Diseases  of  Women.     146  Illus.    5th  Ed.     In  Press. 

WELLS.  Compend  of  Gynecology.   Illus.  .80;   Interleaved,  $1.25 

WINCKEL.  Diseases  of  Women.  Translated  by  special  authority 
of  Author,  under  the  Supervision  of,  and  with  an  Introduction  by, 
Theophilus  Parvin,  m.d.  152  Engravings  on  Wood.  3d  Edition, 
Revised.  In  Preparation. 

FULLERTON.  Nursing  in  Abdominal  Surgery  and  Diseases 
of  Women.     2d  Edition.     70  Illustrations.  }i  50 


22  SUBJECT  CATALOGUE. 

COMPENDS. 


From.  The  Southern  Clinic. 

"  We  know  of  no  series  of  books  issued  by  any  house  that  so  fully 
meets  our  approval  as  these  ?  Quiz-Compends?.  They  are  well  ar- 
ranged, full,  and  concise,  and  are  really  the  best  line  of  text-books  that 
could  be  found  for  either  student  or  practitioner." 


BLAKISTON'S  ?  QUIZ-COMPENDS? 

The  Best  Series  of  Manuals  for  the  Use  of  Students. 
Price  of  each,  Cloth,  .80.         Interleaved,  for  taking  Notes,  $1.25. 

4®*  These  Compends  are  based  on  the  most  popular  text-books 
and  the  lectures  of  prominent  professors,  and  are  kept  constantly  re- 
vised, so  that  they  may  thoroughly  represent  the  present  state  of  the 
subjects  upon  which  they  treat. 

4®"  The  authors  have  had  large  experience  as  Quiz-Masters  and 
attaches  of  colleges,  and  are  well  acquainted  with  the  wants  of  students. 

&S~  They  are  arranged  in  the  most  approved  form,  thorough  and 
concise,  containing  over  6oo  fine  illustrations,  inserted  wherever  they 
could  be  used  to  advantage. 

4Sf*  Can  be  used  by  students  ot  any  college. 

4ST"  They  contain  information  nowhere  else  collected  in  such  a 
condensed,  practical  shape.     Illustrated  Circular  free. 

No.  i.  POTTER.  HUMAN  ANATOMY.  Fifth  Revised  and 
Enlarged  Edition.  Including  Visceral  Anatomy.  Can  be  used 
with  either  Morris's  or  Gray's  Anatomy.  117  Illustrations  and  16 
Lithographic  Plates  of  Nerves  and  Arteries,  with  Explanatory 
Tables,  etc.  By  Samuel  O.  L.  Potter,  m.d.,  Professor  of  the 
Practice  of  Medicine,  Cooper  Medical  College,  San  Francisco  ;  late 
A.  A.  Surgeon,  U.  S.  Army. 

No.  2.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  I.  Fifth 
Edition,  Enlarged  and  Improved.  By  Daniel  E.  Hughes,  m.d., 
Physician-in-Chief,  Philadelphia  Hospital,  late  Demonstrator  ot 
Clinical  Medicine,  Jefferson  Medical  College,  Phila. 

No.  3.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  II. 
Fifth  Edition,  Revised  and  Improved.     Same  author  as  No.  2. 

No.  4.  BRUBAKER.  PHYSIOLOGY.  Eighth  Edition,  with 
new  Illustrations  and  a  table  of  Physiological  Constants.  Enlarged 
and  Revised.  By  A.  P.  Brubaker,  m.d.,  Professor  of  Physiology 
and  General  Pathology  in  the  Pennsylvania  College  of  Dental 
Surgery  ;  Demonstrator  of  Physiology,  Jefferson  Medical  College, 
Philadelphia. 

No.  5.  LANDIS.  OBSTETRICS.  Fifth  Edition.  By  Henry  G. 
Landis,  m.d.  Revised  and  Edited  by  Wm.  H.  Wells,  m.d., 
Assistant  Demonstrator  of  Obstetrics,  Jefferson  Medical  College, 
Philadelphia.     Enlarged.     47  Illustrations. 

No.  6.  POTTER.  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PRESCRIPTION  WRITING.  Sixth  Revised  Edition 
(U.  S.  P.  1890).  By  Samuel  O.  L.  Potter,  m.d.,  Professor  of 
Practice,  Cooper  Medical  College,  San  Francisco  ;  late  A.  A.  Sur- 
geon, U.  S.  Army. 


MEDICAL   BOOKS.  23 


PQUIZ-COMPENDS  ?— Continued. 

No.  7.  WELLS.  GYNECOLOGY.  A  New  Book.  By  W11. 
H.  Wells,  m.d.,  Assistant  Demonstrator  of  Obstetrics,  JeffersOD 
College,  Philadelphia.     150  Illustrations. 

No.  8.  GOULD  AND  PYLE.  DISEASES  OF  THE  EYE 
AND  REFRACTION.  A  New  Book.  Including  Treatment 
and  Surgery,  and  a  Section  on  Local  Therapeutics.  By  George 
M.  Gould,  m.d.,  and  W.  L.  Pyle,  m.d.  With  Formulae,  Glossary, 
Tables,  and  m  Illustrations,  several  of  which  are  Colored. 

No.  9.  HORWITZ.  SURGERY,  Minor  Surgery,  and  Bandag- 
ing. Fifth  Edition,  Enlarged  and  Improved.  By  Orvillb 
Horwitz,  b.s.,  m.d.,  Clinical  Professor  of  Genito-Urinary  Surgery 
and  Venereal  Diseases  in  Jefferson  Medical  College  ;  Surgeon  to 
Philadelphia  Hospital,  etc.    With  98  Formulae  and  71  Illustrations. 

No.  10.  LEFFMANN.  MEDICAL  CHEMISTRY.  Fourth 
Edition.  Including  Urinalysis,  Animal  Chemistry,  Chemistry  of 
Milk,  Blood,  Tissues,  the  Secretions, etc.  By  Henry  Lbfpmann, 
m.d.,  Professor  of  Chemistry  in  Pennsylvania  College  of  Dental 
Surgery  and  in  the  Woman's  Medical  College,  Philadelphia. 

No.  11.  STEWART.  PHARMACY.  Fifth  Edition.  Based  upon 
Prof.  Remington's  Text-Book  of  Pharmacy.  By  F.  E.  Stewart, 
m.d.,  ph.g.,  late  Quiz-Master  in  Pharmacy  and  Chemistry,  Phila- 
delphia College  of  Pharmacy ;  Lecturer  at  Jefferson  Medical 
College.     Carefully  revised  in  accordance  with  the  new  U.  S.  P. 

No.  12.  BALLOU.  VETERINARY  ANATOMY  AND  PHY- 
SIOLOGY. Illustrated.  By  Wm.  R.  Ballou,  m.d.,  Professor 
of  Equine  Anatomy  at  New  York  College  of  Veterinary  Surgeons  ; 
Physician  to  Bellevue  Dispensary,  etc.     29  graphic  Illustrations. 

No.  13.  WARREN.  DENTAL  PATHOLOGY  AND  DEN- 
TAL MEDICINE.  Third  Edition,  Illustrated.  Containing 
a  Section  on  Emergencies.  By  Geo.  W.  Warren,  d.d.s.,  Chief 
of  Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery. 

No.  14.  HATFIELD.  DISEASES  OF  CHILDREN.  Second 
Edition.  Colored  Plate.  By  Marcus  P.  Hatfield,  Profes- 
sor of  Diseases  of  Children,  Chicago  Medical  College. 

No.  15.  HALL.  GENERAL  PATHOLOGY  AND  MORBID 
ANATOMY.  91  Illustrations.  By  H.  Nkwberry  Hall,  ph.g., 
m.d.,  late  Professor  of  Pathology,  Chicago  Post-Graduate  Medi- 
cal School. 

No.  16.  DISEASES  OF  THE  SKIN.  By  Jay  T.  Schamberg, 
m.d.,  Instructor  in  Skin  Diseases,  Philadelphia  Polyclinic.     Illus. 

Price,  each,  Cloth,  .80.  Interleaved,  for  taking  Notes,  $1.25. 

In  preparing,  revising,  and  improving  Blakiston's  ?Quiz-Com- 
pendsT  the  particular  wants  of  the  student  have  always  been  kept  in 
mind. 

Careful  attention  has  been  given  to  the  construction  of  each  sentence, 
and  while  the  books  will  be  found  to  contain  an  immense  amount  of 
knowledge  in  small  space,  they  will  likewise  be  found  easy  reading; 
there  is  no  stilted  repetition  of  words  ;  the  style  is  clear,  lucid,  and  dis- 
tinct. The  arrangement  of  subjects  is  systematic  and  thorough  ;  there 
is  a  reason  for  every  word.     They  contain  over  600  illustrations. 


Tyson's 
Practice  of 
Medicine.  ::l!i?z 


Text-Book  of  the  Practice  of  Medi- 
cine. With  Special  Reference  to  Diagnosis 
and  Treatment.  By  James  Tyson,  m.  d., 
Frofessor  of  Clinical  Medicine  in  the  Univer- 
sity of  Pennsylvania;  Physician  to  the  Hos- 
pital of  the  University  and  to  the  Philadelphia 
Hospital ;  Fellow  of  the  College  of  Physicians 
of  Philadelphia,  etc. 


With  Many  Useful  Illustrations. 

Octavo.      1180  Pages. 

Cloth,  $5.50;  Sheep,  $6.50;  Half  Russia,  $7.50. 


Extracts  from  a  Review  in  the  American  Journal  oj 
Medical  Sciences,  March,  1897: 

"  Externally  it  is  the  largest  and  handsomest  single  volume 
on  the  practice  of  medicine." 

"  Clinical  features  are  usually  described  in  a  masterly  way." 

"The  directions  (ior  treatment)  are  full  and  clear,  and  as 
a  rule,  eminently  judicious  and  conservative." 

"Dr.  Tyson's  style  is  already  so  well  known  in  medical 
literature  that  it  is  only  necessary  to  say  the  present  work  is 
one  of  the  best  examples." 

"We  welcome  Dr.  Tyson's  Practice  as  a  most  valuable 
addition  to  medical  literature." 

Descriptive  circular  and  sample  pages  upon  application. 


UC  SOUTHERN  REGION/ 


AA      000  221  247    o 


